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Levy Y, Rempel D, Nguyen M, Yassine A, Sanati-Burns M, Salgia P, Lim B, Butler SL, Berkeley A, Bayram E. The Fusion of Wide Field Optical Coherence Tomography and AI: Advancing Breast Cancer Surgical Margin Visualization. Life (Basel) 2023; 13:2340. [PMID: 38137941 PMCID: PMC10744864 DOI: 10.3390/life13122340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 11/23/2023] [Accepted: 12/08/2023] [Indexed: 12/24/2023] Open
Abstract
This study explores the integration of Wide Field Optical Coherence Tomography (WF-OCT) with an AI-driven clinical decision support system, with the goal of enhancing productivity and decision making in breast cancer surgery margin assessment. A computationally efficient convolutional neural network (CNN)-based binary classifier is developed using 585 WF-OCT margin scans from 151 subjects. The CNN model swiftly identifies suspicious areas within margins with an on-device inference time of approximately 10 ms for a 420 × 2400 image. In independent testing on 155 pathology-confirmed margins, including 31 positive margins from 29 patients, the classifier achieved an AUROC of 0.976, a sensitivity of 0.93, and a specificity of 0.98. At the margin level, the deep learning model accurately identified 96.8% of pathology-positive margins. These results highlight the clinical viability of AI-enhanced margin visualization using WF-OCT in breast cancer surgery and its potential to decrease reoperation rates due to residual tumors.
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Affiliation(s)
- Yanir Levy
- Perimeter Medical Imaging AI Inc., 555 Richmond St W #511, Toronto, ON M5V 3B1, Canada; (D.R.); (M.S.-B.); (A.B.)
| | - David Rempel
- Perimeter Medical Imaging AI Inc., 555 Richmond St W #511, Toronto, ON M5V 3B1, Canada; (D.R.); (M.S.-B.); (A.B.)
| | - Mark Nguyen
- Perimeter Medical Imaging AI Inc., 8585 N Stemmons Fwy Suite 106N, Dallas, TX 75247, USA; (M.N.); (P.S.); (S.L.B.)
| | - Ali Yassine
- The Edward S. Rogers Sr. Department of Electrical & Computer Engineering, University of Toronto, 27 King’s College Cir, Toronto, ON M5S 1A1, Canada;
| | - Maggie Sanati-Burns
- Perimeter Medical Imaging AI Inc., 555 Richmond St W #511, Toronto, ON M5V 3B1, Canada; (D.R.); (M.S.-B.); (A.B.)
| | - Payal Salgia
- Perimeter Medical Imaging AI Inc., 8585 N Stemmons Fwy Suite 106N, Dallas, TX 75247, USA; (M.N.); (P.S.); (S.L.B.)
| | - Bryant Lim
- The Institute of Biomedical Engineering, University of Toronto, 27 King’s College Cir, Toronto, ON M5S 1A1, Canada;
| | - Sarah L. Butler
- Perimeter Medical Imaging AI Inc., 8585 N Stemmons Fwy Suite 106N, Dallas, TX 75247, USA; (M.N.); (P.S.); (S.L.B.)
| | - Andrew Berkeley
- Perimeter Medical Imaging AI Inc., 555 Richmond St W #511, Toronto, ON M5V 3B1, Canada; (D.R.); (M.S.-B.); (A.B.)
| | - Ersin Bayram
- Perimeter Medical Imaging AI Inc., 8585 N Stemmons Fwy Suite 106N, Dallas, TX 75247, USA; (M.N.); (P.S.); (S.L.B.)
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2
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Byrd BK, Wells WA, Strawbridge RR, Barth CW, Samkoe KS, Gibbs SL, Davis SC. Evaluating Receptor-Specific Fresh Specimen Staining for Tumor Margin Detection in Clinical Breast Specimens. Mol Imaging Biol 2023; 25:911-922. [PMID: 37351769 PMCID: PMC10598096 DOI: 10.1007/s11307-022-01771-9] [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: 07/01/2022] [Revised: 08/22/2022] [Accepted: 09/06/2022] [Indexed: 06/24/2023]
Abstract
PURPOSE Reliable and rapid identification of tumor in the margins of breast specimens during breast-conserving surgery to reduce repeat surgery rates is an active area of investigation. Dual-stain difference imaging (DDSI) is one of many approaches under evaluation for this application. This technique aims to topically apply fluorescent stain pairs (one targeted to a receptor-of-interest and the other a spectrally distinct isotype), image both stains, and compute a normalized difference image between the two channels. Prior evaluation and optimization in a variety of preclinical models produced encouraging diagnostic performance. Herein, we report on a pilot clinical study which evaluated HER2-targeted DDSI on 11 human breast specimens. PROCEDURES Gross sections from 11 freshly excised mastectomy specimens were processed using a HER2-receptor-targeted DDSI protocol shortly after resection. After staining with the dual-probe protocol, specimens were imaged on a fluorescence scanner, followed by tissue fixation for hematoxylin and eosin and anti-HER2 immunohistochemical staining. Receiver operator characteristic curves and area under the curve (AUC) analysis were used to assess diagnostic performance of the resulting images. Performance values were also compared to expression level determined from IHC staining. RESULTS Eight of the 11 specimens presented with distinguishable invasive ductal carcinoma and/or were not affected by an imaging artifact. In these specimens, the DDSI technique provided an AUC = 0.90 ± 0.07 for tumor-to-adipose tissue and 0.81 ± 0.15 for tumor-to-glandular tissue, which was significantly higher than AUC values recovered from images of the targeted probe alone. DDSI values and diagnostic performance did not correlate with HER2 expression level, and tumors with low HER2 expression often produced high AUC, suggesting that even the low expression levels were enough to help distinguish tumor. CONCLUSIONS The results from this preliminary study of rapid receptor-specific staining in human specimens were consistent with prior preclinical results and demonstrated promising diagnostic potential.
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Affiliation(s)
- Brook K Byrd
- Thayer School of Engineering, Dartmouth College, Hanover, NH, 03755, USA
| | - Wendy A Wells
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, 03766, USA
| | | | - Connor W Barth
- Biomedical Engineering Department, Oregon Health & Science University, Portland, OR, 97201, USA
| | - Kimberley S Samkoe
- Thayer School of Engineering, Dartmouth College, Hanover, NH, 03755, USA
| | - Summer L Gibbs
- Biomedical Engineering Department, Oregon Health & Science University, Portland, OR, 97201, USA
| | - Scott C Davis
- Thayer School of Engineering, Dartmouth College, Hanover, NH, 03755, USA.
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3
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Ryan JF, Lesniak DM, Cordeiro E, Campbell SM, Rajaee AN. Surgeon Factors Influencing Breast Surgery Outcomes: A Scoping Review to Define the Modern Breast Surgical Oncologist. Ann Surg Oncol 2023; 30:4695-4713. [PMID: 37036590 DOI: 10.1245/s10434-023-13472-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/26/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Modern breast surgical oncology incorporates many aspects of care including preoperative workup, surgical management, and multidisciplinary collaboration to achieve favorable oncologic outcomes and high patient satisfaction. However, there is variability in surgical practice and outcomes. This review aims to identify modifiable surgeon factors influencing breast surgery outcomes and provide a definition of the modern breast surgical oncologist. METHODS A systematic literature search with additional backward citation searching was conducted. Studies describing modifiable surgeon factors with associated breast surgery outcomes such as rates of breast conservation, sentinel node biopsy, re-excision, complications, acceptable esthetic outcome, and disease-free and overall survival were included. Surgeon factors were categorized for qualitative analysis. RESULTS A total of 91 studies met inclusion criteria describing both modifiable surgeon factor and outcome data. Four key surgeon factors associated with improved breast surgery outcomes were identified: surgical volume (45 studies), use of oncoplastic techniques (41 studies), sub-specialization in breast surgery or surgical oncology (9 studies), and participation in professional development activities (5 studies). CONCLUSIONS On the basis of the literature review, the modern breast surgical oncologist has a moderate- to high-volume breast surgery practice, understands the use and application of oncoplastic breast surgery, engages in additional training opportunities, maintains memberships in relevant societies, and remains up to date on key literature. Surgeons practicing in breast surgical oncology can target these modifiable factors for professional development and quality improvement.
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Affiliation(s)
- Joanna F Ryan
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - David M Lesniak
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - Erin Cordeiro
- Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Sandra M Campbell
- John W. Scott Health Sciences Library, University of Alberta, Edmonton, Canada
| | - A Nikoo Rajaee
- Department of Surgery, University of Alberta, Edmonton, Canada.
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4
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Liu P, Zhao Y, Rong DD, Li KF, Wang YJ, Zhao J, Kang H. Diagnostic value of preoperative examination for evaluating margin status in breast cancer. World J Clin Cases 2023; 11:4852-4864. [PMID: 37583993 PMCID: PMC10424046 DOI: 10.12998/wjcc.v11.i20.4852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/08/2023] [Accepted: 06/21/2023] [Indexed: 07/11/2023] Open
Abstract
BACKGROUND A positive resection margin is a major risk factor for local breast cancer recurrence after breast-conserving surgery (BCS). Preoperative imaging examinations are frequently employed to assess the surgical margin. AIM To investigate the role and value of preoperative imaging examinations [magnetic resonance imaging (MRI), molybdenum target, and ultrasound] in evaluating margins for BCS. METHODS A retrospective study was conducted on 323 breast cancer patients who met the criteria for BCS and consented to the procedure from January 2014 to July 2021. The study gathered preoperative imaging data (MRI, ultrasound, and molybdenum target examination) and intraoperative and postoperative pathological information. Based on their BCS outcomes, patients were categorized into positive and negative margin groups. Subsequently, the patients were randomly split into a training set (226 patients, approximately 70%) and a validation set (97 patients, approximately 30%). The imaging and pathological information was analyzed and summarized using R software. Non-conditional logistic regression and LASSO regression were conducted in the validation set to identify factors that might influence the failure of BCS. A column chart was generated and applied to the validation set to examine the relationship between pathological margin range and prognosis. This study aims to identify the risk factors associated with failure in BCS. RESULTS The multivariate non-conditional logistic regression analysis demonstrated that various factors raise the risk of positive margins following BCS. These factors comprise non-mass enhancement (NME) on dynamic contrast-enhanced MRI, multiple focal vascular signs around the lesion on MRI, tumor size exceeding 2 cm, type III time-signal intensity curve, indistinct margins on molybdenum target examination, unclear margins on ultrasound examination, and estrogen receptor (ER) positivity in immunohistochemistry. LASSO regression was additionally employed in this study to identify four predictive factors for the model: ER, molybdenum target tumor type (MT Xmd Shape), maximum intensity projection imaging feature, and lesion type on MRI. The model constructed with these predictive factors exhibited strong consistency with the real-world scenario in both the training set and validation set. Particularly, the outcomes of the column chart model accurately predicted the likelihood of positive margins in BCS. CONCLUSION The proposed column chart model effectively predicts the success of BCS for breast cancer. The model utilizes preoperative ultrasound, molybdenum target, MRI, and core needle biopsy pathology evaluation results, all of which align with the real-world scenario. Hence, our model can offer dependable guidance for clinical decision-making concerning BCS.
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Affiliation(s)
- Peng Liu
- Department of General Surgery, Center for Thyroid and Breast Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
- Department of General Surgery, Beijing Fengtai Hospital, Beijing 100071, China
| | - Ye Zhao
- Department of General Surgery, Center for Thyroid and Breast Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Dong-Dong Rong
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Kai-Fu Li
- Department of General Surgery, Center for Thyroid and Breast Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Ya-Jun Wang
- Department of General Surgery, Center for Thyroid and Breast Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Jing Zhao
- Department of General Surgery, Center for Thyroid and Breast Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Hua Kang
- Department of General Surgery, Center for Thyroid and Breast Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
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5
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Liu P, Zhao Y, Rong DD, Li KF, Wang YJ, Zhao J, Kang H. Diagnostic value of preoperative examination for evaluating margin status in breast cancer. World J Clin Cases 2023; 11:4848-4860. [DOI: 10.12998/wjcc.v11.i20.4848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/08/2023] [Accepted: 06/21/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND A positive resection margin is a major risk factor for local breast cancer recurrence after breast-conserving surgery (BCS). Preoperative imaging examinations are frequently employed to assess the surgical margin.
AIM To investigate the role and value of preoperative imaging examinations [magnetic resonance imaging (MRI), molybdenum target, and ultrasound] in evaluating margins for BCS.
METHODS A retrospective study was conducted on 323 breast cancer patients who met the criteria for BCS and consented to the procedure from January 2014 to July 2021. The study gathered preoperative imaging data (MRI, ultrasound, and molybdenum target examination) and intraoperative and postoperative pathological information. Based on their BCS outcomes, patients were categorized into positive and negative margin groups. Subsequently, the patients were randomly split into a training set (226 patients, approximately 70%) and a validation set (97 patients, approximately 30%). The imaging and pathological information was analyzed and summarized using R software. Non-conditional logistic regression and LASSO regression were conducted in the validation set to identify factors that might influence the failure of BCS. A column chart was generated and applied to the validation set to examine the relationship between pathological margin range and prognosis. This study aims to identify the risk factors associated with failure in BCS.
RESULTS The multivariate non-conditional logistic regression analysis demonstrated that various factors raise the risk of positive margins following BCS. These factors comprise non-mass enhancement (NME) on dynamic contrast-enhanced MRI, multiple focal vascular signs around the lesion on MRI, tumor size exceeding 2 cm, type III time-signal intensity curve, indistinct margins on molybdenum target examination, unclear margins on ultrasound examination, and estrogen receptor (ER) positivity in immunohistochemistry. LASSO regression was additionally employed in this study to identify four predictive factors for the model: ER, molybdenum target tumor type (MT Xmd Shape), maximum intensity projection imaging feature, and lesion type on MRI. The model constructed with these predictive factors exhibited strong consistency with the real-world scenario in both the training set and validation set. Particularly, the outcomes of the column chart model accurately predicted the likelihood of positive margins in BCS.
CONCLUSION The proposed column chart model effectively predicts the success of BCS for breast cancer. The model utilizes preoperative ultrasound, molybdenum target, MRI, and core needle biopsy pathology evaluation results, all of which align with the real-world scenario. Hence, our model can offer dependable guidance for clinical decision-making concerning BCS.
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Affiliation(s)
- Peng Liu
- Department of General Surgery, Center for Thyroid and Breast Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
- Department of General Surgery, Beijing Fengtai Hospital, Beijing 100071, China
| | - Ye Zhao
- Department of General Surgery, Center for Thyroid and Breast Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Dong-Dong Rong
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Kai-Fu Li
- Department of General Surgery, Center for Thyroid and Breast Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Ya-Jun Wang
- Department of General Surgery, Center for Thyroid and Breast Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Jing Zhao
- Department of General Surgery, Center for Thyroid and Breast Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Hua Kang
- Department of General Surgery, Center for Thyroid and Breast Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
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6
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Automated breast ultrasound (ABUS) for intraoperative margin control on surgical specimens in breast conserving surgery. Arch Gynecol Obstet 2022; 307:1949-1955. [PMID: 36503976 DOI: 10.1007/s00404-022-06837-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 10/23/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE As breast-conserving surgery (BCS) has become the standard for treatment of early breast cancer, the need for new technologies to improve intraoperative margin assessment has become clear. Close or positive margins during BCS lead to additional surgeries, treatment delay, additional stress for patients and increasing healthcare cost. Automated three-dimensional breast ultrasound (ABUS) systems are meant to overcome the shortcomings of hand-held ultrasound (HHUS). In this study, we investigate the feasibility of ABUS to conduct ultrasound on surgical specimens in breast conserving therapy. METHODS In this monocentric, non-interventional study, specimens of 40 women were examined via ABUS. A construction with isotonic saline solution, gel pads and ABUS membranes was invented by our team to produce images of breast cancer specimens using ABUS. Evaluation of the ABUS images was carried out by two independent physicians trained on ABUS evaluation. RESULTS ABUS was conducted on 40 specimens. 90% of the generated images were of high quality. Measured tumor sizes with ABUS were bigger than measured tumor size with HHUS (mean tumor size 22.9 vs. 18.1 mm, CI 2.38-7.35, p < 0.05). The mean difference between the ABUS tumor size and the pathological tumor size was 1.8 mm (CI - 0.84-4.53, p = 0.17). The mean difference between the HHUS tumor size and the pathological tumor size was 3.2 mm (CI - 5.35 to - 1.03, p = 0.005). CONCLUSION ABUS seems to be a suitable method to conduct specimen ultrasound. Further studies are required to evaluate the accuracy of ABUS for intraoperative margin assessment and possible implementation in clinical work routine.
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7
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Gong P, Chin SL, Allen WM, Ballal H, Anstie JD, Chin L, Ismail HM, Zilkens R, Lakhiani DD, McCarthy M, Fang Q, Firth D, Newman K, Thomas C, Li J, Sanderson RW, Foo KY, Yeomans C, Dessauvagie BF, Latham B, Saunders CM, Kennedy BF. Quantitative Micro-Elastography Enables In Vivo Detection of Residual Cancer in the Surgical Cavity during Breast-Conserving Surgery. Cancer Res 2022; 82:4093-4104. [PMID: 36098983 PMCID: PMC9627129 DOI: 10.1158/0008-5472.can-22-0578] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/29/2022] [Accepted: 09/08/2022] [Indexed: 01/07/2023]
Abstract
Breast-conserving surgery (BCS) is commonly used for the treatment of early-stage breast cancer. Following BCS, approximately 20% to 30% of patients require reexcision because postoperative histopathology identifies cancer in the surgical margins of the excised specimen. Quantitative micro-elastography (QME) is an imaging technique that maps microscale tissue stiffness and has demonstrated a high diagnostic accuracy (96%) in detecting cancer in specimens excised during surgery. However, current QME methods, in common with most proposed intraoperative solutions, cannot image cancer directly in the patient, making their translation to clinical use challenging. In this proof-of-concept study, we aimed to determine whether a handheld QME probe, designed to interrogate the surgical cavity, can detect residual cancer directly in the breast cavity in vivo during BCS. In a first-in-human study, 21 BCS patients were scanned in vivo with the QME probe by five surgeons. For validation, protocols were developed to coregister in vivo QME with postoperative histopathology of the resected tissue to assess the capability of QME to identify residual cancer. In four cavity aspects presenting cancer and 21 cavity aspects presenting benign tissue, QME detected elevated stiffness in all four cancer cases, in contrast to low stiffness observed in 19 of the 21 benign cases. The results indicate that in vivo QME can identify residual cancer by directly imaging the surgical cavity, potentially providing a reliable intraoperative solution that can enable more complete cancer excision during BCS. SIGNIFICANCE Optical imaging of microscale tissue stiffness enables the detection of residual breast cancer directly in the surgical cavity during breast-conserving surgery, which could potentially contribute to more complete cancer excision.
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Affiliation(s)
- Peijun Gong
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia.,Corresponding Author: Peijun Gong, BRITElab, Harry Perkins Institute of Medical Research, Perth 6009, Australia. Phone: 61-8-6488-6774; E-mail:
| | - Synn Lynn Chin
- Breast Centre, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Wes M. Allen
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Helen Ballal
- Breast Centre, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - James D. Anstie
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Lixin Chin
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Hina M. Ismail
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Renate Zilkens
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Division of Surgery, Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Devina D. Lakhiani
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | | | - Qi Fang
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Daniel Firth
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Kyle Newman
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Caleb Thomas
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Jiayue Li
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia.,Australian Research Council Centre for Personalised Therapeutics Technologies, Melbourne, Victoria, Australia
| | - Rowan W. Sanderson
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Ken Y. Foo
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Chris Yeomans
- PathWest, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Benjamin F. Dessauvagie
- PathWest, Fiona Stanley Hospital, Murdoch, Western Australia, Australia.,Division of Pathology and Laboratory Medicine, Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Bruce Latham
- PathWest, Fiona Stanley Hospital, Murdoch, Western Australia, Australia.,The University of Notre Dame, Fremantle, Western Australia, Australia
| | - Christobel M. Saunders
- Breast Centre, Fiona Stanley Hospital, Murdoch, Western Australia, Australia.,Division of Surgery, Medical School, The University of Western Australia, Perth, Western Australia, Australia.,Breast Clinic, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Brendan F. Kennedy
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia.,Australian Research Council Centre for Personalised Therapeutics Technologies, Melbourne, Victoria, Australia
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8
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De-Escalating the Management of In Situ and Invasive Breast Cancer. Cancers (Basel) 2022; 14:cancers14194545. [PMID: 36230468 PMCID: PMC9559495 DOI: 10.3390/cancers14194545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/01/2022] [Accepted: 09/11/2022] [Indexed: 11/20/2022] Open
Abstract
Simple Summary De-escalation of breast cancer treatment reduces morbidity and toxicity for patients. De-escalation is safe if cancer outcomes, such as recurrence and survival, remain unaffected compared to more radical regimens. This review provides an overview on treatment de-escalation for ductal carcinoma in situ (DCIS), local treatment of breast cancer, and surgery after neoadjuvant systemic therapy. Improvements in understanding the natural history and biology of breast cancer, imaging modalities, and adjuvant treatments have facilitated de-escalation of treatment over time. Abstract It is necessary to identify appropriate areas of de-escalation in breast cancer treatment to minimize morbidity and maximize patients’ quality of life. Less radical treatment modalities, or even no treatment, have been reconsidered if they offer the same oncologic outcomes as standard therapies. Identifying which patients benefit from de-escalation requires particular care, as standard therapies will continue to offer adequate cancer outcomes. We provide an overview of the literature on the de-escalation of treatment of ductal carcinoma in situ (DCIS), local treatment of breast cancer, and surgery after neoadjuvant systemic therapy. De-escalation of breast cancer treatment is a key area of investigation that will continue to remain a priority. Improvements in understanding the natural history and biology of breast cancer, imaging modalities, and adjuvant treatments will expand this even further. Future efforts will continue to challenge us to consider the true role of various treatment modalities.
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9
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Amiri SA, Berckel PV, Lai M, Dankelman J, Hendriks BHW. Tissue-mimicking phantom materials with tunable optical properties suitable for assessment of diffuse reflectance spectroscopy during electrosurgery. BIOMEDICAL OPTICS EXPRESS 2022; 13:2616-2643. [PMID: 35774339 PMCID: PMC9203083 DOI: 10.1364/boe.449637] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 02/08/2022] [Accepted: 02/09/2022] [Indexed: 06/15/2023]
Abstract
Emerging intraoperative tumor margin assessment techniques require the development of more complex and reliable organ phantoms to assess the performance of the technique before its translation into the clinic. In this work, electrically conductive tissue-mimicking materials (TMMs) based on fat, water and agar/gelatin were produced with tunable optical properties. The composition of the phantoms allowed for the assessment of tumor margins using diffuse reflectance spectroscopy, as the fat/water ratio served as a discriminating factor between the healthy and malignant tissue. Moreover, the possibility of using polyvinyl alcohol (PVA) or transglutaminase in combination with fat, water and gelatin for developing TMMs was studied. The diffuse spectral response of the developed phantom materials had a good match with the spectral response of porcine muscle and adipose tissue, as well as in vitro human breast tissue. Using the developed recipe, anatomically relevant heterogeneous breast phantoms representing the optical properties of different layers of the human breast were fabricated using 3D-printed molds. These TMMs can be used for further development of phantoms applicable for simulating the realistic breast conserving surgery workflow in order to evaluate the intraoperative optical-based tumor margin assessment techniques during electrosurgery.
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Affiliation(s)
- Sara Azizian Amiri
- Department of Biomechanical Engineering, Faculty of Mechanical, Maritime, and Materials Engineering, Delft University of Technology, The Netherlands
| | - Pieter Van Berckel
- Department of Biomechanical Engineering, Faculty of Mechanical, Maritime, and Materials Engineering, Delft University of Technology, The Netherlands
| | - Marco Lai
- Philips Research, IGT & US Devices and Systems Department, Eindhoven, The Netherlands
- Eindhoven University of Technology (TU/e), Eindhoven, The Netherlands
| | - Jenny Dankelman
- Department of Biomechanical Engineering, Faculty of Mechanical, Maritime, and Materials Engineering, Delft University of Technology, The Netherlands
| | - Benno H. W. Hendriks
- Department of Biomechanical Engineering, Faculty of Mechanical, Maritime, and Materials Engineering, Delft University of Technology, The Netherlands
- Philips Research, IGT & US Devices and Systems Department, Eindhoven, The Netherlands
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10
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Gulcelik MA, Dogan L, Karaman N, Bahcecitapar M, Ozaslan C. Oncoplastic Level II Surgical Techniques for Breast Cancer Treatment: Long-Term Outcomes. Breast Care (Basel) 2022; 17:24-30. [PMID: 35355700 PMCID: PMC8914188 DOI: 10.1159/000514468] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 01/16/2021] [Indexed: 02/03/2023] Open
Abstract
Background Problems in patients who could not get adequate surgical margins (SM) and good cosmetic results with breast-conserving surgery (BCS) have been overcome with the introduction of oncoplastic surgery (OPS) methods. The purpose of this study was the documentation of level II techniques and the presentation of long-term survival results. Methods The data on patients who had been prospectively registered in the database between 2007 and 2017 and who had been treated with level II OPS due to invasive breast cancer were examined. Results A total of 1,074 patients were included in the study. The most commonly applied level II oncoplastic techniques were performed in the upper outer quadrantectomy with racquet incision in 334 (31%) patients, inferior pedicle flaps in 294 (27.3%), and vertical mammoplasty in 140 (13%). Reexcision was performed in 96 patients (8.9%). Total breast conservation rate was 96%. Five-year disease-free survival (DFS) was 88%, local recurrence-free survival (LRFS) 93.6%, and overall survival (OS) 96%. Ten-year DFS was 72%, LRFS 85.4%, and OS 90.2%. Conclusion Level II OPS techniques have low reoperation and complication rates and a high rate of breast protection. The success of these techniques has been demonstrated in terms of long-term local control. Awareness of the fact that many patients who undergo OPS will not lose their breasts should be created, and regular training programs for OPS techniques should be conducted especially in developing countries. By revealing these results, it is hoped that the OPS and breast conservation rates will increase.
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Affiliation(s)
- Mehmet Ali Gulcelik
- Department of Surgical Oncology, University of Health Sciences, Gülhane Training and Research Hospital, Ankara, Turkey
| | - Lutfi Dogan
- Department of Surgical Oncology, University of Health Sciences, Ankara Oncology Training and Research Hospital, Ankara, Turkey,*Lutfi Dogan, Department of Surgical Oncology, University of Health Sciences, Ankara Oncology Training and Research Hospital, Ankara 06200 (Turkey),
| | - Niyazi Karaman
- Department of Surgical Oncology, University of Health Sciences, Ankara Oncology Training and Research Hospital, Ankara, Turkey
| | - Melike Bahcecitapar
- Department of Statistics, Hacettepe University, Faculty of Science, Ankara, Turkey
| | - Cihangir Ozaslan
- Department of Surgical Oncology, University of Health Sciences, Ankara Oncology Training and Research Hospital, Ankara, Turkey
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11
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Yoo TK, Kang YJ, Jeong J, Song JY, Kang SH, Lee HY, Kim ET, Yi O, Lee HB, Choi S, Park HS, Gwak G, Kim JI, Kim MK, Lee J, Kang HJ, Chae BJ. A Randomized Controlled Trial for Doing vs. Omitting Intraoperative Frozen Section Biopsy for Resection Margin Status in Selected Patients Undergoing Breast-Conserving Surgery (OFF-MAP Trial). J Breast Cancer 2022; 24:569-577. [PMID: 34979601 PMCID: PMC8724377 DOI: 10.4048/jbc.2021.24.e51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 10/04/2021] [Accepted: 12/06/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose Intraoperative frozen section biopsy is used to reduce the margin positive rate and re-excision rate and has been reported to have high diagnostic accuracy. A majority of breast surgeons in the Republic of Korea routinely perform frozen section biopsy to assess margins intraoperatively, despite its long turnaround time and high resource requirements. This study aims to determine whether omitting frozen section biopsy for intraoperative margin evaluation in selected patients is non-inferior to performing frozen section biopsy in terms of resection margin positivity rate. Methods This study is a phase III, randomized controlled, parallel-group, multicenter non-inferiority clinical trial. Patients meeting the inclusion criteria and providing written informed consent will be randomized to the “frozen section biopsy” or “frozen section biopsy omission” group after lumpectomy. Patients with clinical stage T1–T3 disease who are diagnosed with invasive breast cancer by core-needle biopsy and plan to undergo breast-conserving surgery will be included in this study. If a daughter nodule, non-mass enhancement, or microcalcification is identified on preoperative imaging, these features must be within 1 cm of the main mass for inclusion in the trial. The target sample size is 646 patients per arm. The primary endpoint will be the resection margin positive rate, and the secondary endpoints include the reoperation rate, operating time, residual cancer after reoperation, residual cancer after re-excision according to the frozen section biopsy result, resection volume, patient quality of life, and cost-effectiveness. Discussion This is the first randomized clinical trial utilizing frozen section biopsy for intraoperative margin evaluation and aims to determine the non-inferiority of omitting frozen section biopsy in selected patients compared to performing frozen section biopsy. We expect that this trial will help surgeons perform the procedure more efficiently while ensuring patient safety. Trial Registration ClinicalTrials.gov Identifier: NCT03975179; Clinical Research Information Service Identifier: KCT0004606
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Affiliation(s)
- Tae-Kyung Yoo
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young-Joon Kang
- Department of Surgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Joon Jeong
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jeong-Yoon Song
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Korea
| | - Sun Hee Kang
- Department of Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Hye Yoon Lee
- Department of Surgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Eui Tae Kim
- Department of Surgery, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
| | - Onvox Yi
- Department of Surgery, Dongnam Institute of Radiological and Medical Science, Busan, Korea
| | - Han-Byoel Lee
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Soojeong Choi
- Department of Surgery, Seoul Medical Center, Seoul, Korea
| | - Hyung Seok Park
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Geumhee Gwak
- Department of Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Jae Il Kim
- Department of Surgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Min Kyoon Kim
- Department of Surgery, Chung-Ang University Hospital, Seoul, Korea
| | - Jeeyeon Lee
- Department of Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Korea
| | - Hee Joon Kang
- Division of Breast and Endocrine Surgery, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Byung Joo Chae
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. ,
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12
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Developing diagnostic assessment of breast lumpectomy tissues using radiomic and optical signatures. Sci Rep 2021; 11:21832. [PMID: 34750471 PMCID: PMC8575781 DOI: 10.1038/s41598-021-01414-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 10/28/2021] [Indexed: 02/07/2023] Open
Abstract
High positive margin rates in oncologic breast-conserving surgery are a pressing clinical problem. Volumetric X-ray scanning is emerging as a powerful ex vivo specimen imaging technique for analyzing resection margins, but X-rays lack contrast between non-malignant and malignant fibrous tissues. In this study, combined micro-CT and wide-field optical image radiomics were developed to classify malignancy of breast cancer tissues, demonstrating that X-ray/optical radiomics improve malignancy classification. Ninety-two standardized features were extracted from co-registered micro-CT and optical spatial frequency domain imaging samples extracted from 54 breast tumors exhibiting seven tissue subtypes confirmed by microscopic histological analysis. Multimodal feature sets improved classification performance versus micro-CT alone when adipose samples were included (AUC = 0.88 vs. 0.90; p-value = 3.65e-11) and excluded, focusing the classification task on exclusively non-malignant fibrous versus malignant tissues (AUC = 0.78 vs. 0.85; p-value = 9.33e-14). Extending the radiomics approach to high-dimensional optical data-termed "optomics" in this study-offers a promising optical image analysis technique for cancer detection. Radiomic feature data and classification source code are publicly available.
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13
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Reid VJ, Falk JS, Police AM, Ridgeway CA, Cadena LL, Povoski SP. Minimizing re-excision after breast conserving surgery - a review of radiofrequency spectroscopy for real-time, intraoperative margin assessment. Expert Rev Med Devices 2021; 18:1057-1068. [PMID: 34657525 DOI: 10.1080/17434440.2021.1992273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION For early-stage breast cancer, breast-conserving surgery (BCS) plus radiation is standard-of-care. Nationwide, >20% of BCS patients require re-excision for positive margins, resulting in delayed adjuvant therapy, increased complications, emotional and financial stress for patients, and additional cost to the healthcare system. Although several methods may be employed to mitigate positive margins, no technique can fully address the need. MarginProbe® is an adjunctive tool for real-time intraoperative margin assessment and is shown to reduce positive margins by >50%. AREAS COVERED Discussion of the impact of re-excision following BCS, a review of currently available methods for intraoperative margin management, followed by a technology and literature review of the MarginProbe® Radiofrequency Spectroscopy System. EXPERT OPINION Re-excision significantly impacts patients, providers and payers. Limitations in the ability to assess margins at time of surgery warrant more advanced methods of residual disease detection. MarginProbe facilitates the most efficient pathway for breast cancer patients through the surgical phase of treatment. The device is well-suited for adoption as the healthcare focus shifts from volume to value and supports the three pillars of the US Department of Health and Human Services' 'Triple-Aim' strategy: improve population health, improve patient experience of care, and reduce per-capita costs.
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Affiliation(s)
- Vincent J Reid
- Director of Surgical Oncology, Medical Director, Hall-Perrine Cancer Center, Cedar Rapids, IA - Clinical Associate Professor of Surgery at the University of Iowa Hospitals and Clinics, USA
| | - Jeffrey S Falk
- Department of Surgery, Ascension St. John Hospital and Medical Center, Detroit, MI - Clinical Associate Professor of Surgery, Wayne State University College of Medicine, St. George's University College of Medicine, USA
| | - Alice M Police
- Director of Breast Surgery, Northwell Health, Western Region, New York, USA
| | - Calvin A Ridgeway
- Medical Director of Breast Care Center, Lovelace Women's Hospital, NM, USA
| | - Lisa L Cadena
- Director, Training and Medical Education, Dilon Technologies, Newport News, VA, USA
| | - Stephen P Povoski
- Professor of Surgery, Division of Surgical Oncology, Department of Surgery, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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14
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Kedrzycki MS, Leiloglou M, Chalau V, Chiarini N, Thiruchelvam PTR, Hadjiminas DJ, Hogben KR, Rashid F, Ramakrishnan R, Darzi AW, Elson DS, Leff DR. The Impact of Temporal Variation in Indocyanine Green Administration on Tumor Identification During Fluorescence Guided Breast Surgery. Ann Surg Oncol 2021; 28:5617-5625. [PMID: 34347221 PMCID: PMC8418597 DOI: 10.1245/s10434-021-10503-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 07/07/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND On average, 21% of women in the USA treated with Breast Conserving Surgery (BCS) undergo a second operation because of close positive margins. Tumor identification with fluorescence imaging could improve positive margin rates through demarcating location, size, and invasiveness of tumors. We investigated the technique's diagnostic accuracy in detecting tumors during BCS using intravenous indocyanine green (ICG) and a custom-built fluorescence camera system. METHODS In this single-center prospective clinical study, 40 recruited BCS patients were sub-categorized into two cohorts. In the first 'enhanced permeability and retention' (EPR) cohort, 0.25 mg/kg ICG was injected ~ 25 min prior to tumor excision, and in the second 'angiography' cohort, ~ 5 min prior to tumor excision. Subsequently, an in-house imaging system was used to image the tumor in situ prior to resection, ex vivo following resection, the resection bed, and during grossing in the histopathology laboratory to compare the technique's diagnostic accuracy between the cohorts. RESULTS The two cohorts were matched in patient and tumor characteristics. The majority of patients had invasive ductal carcinoma with concomitant ductal carcinoma in situ. Tumor-to-background ratio (TBR) in the angiography cohort was superior to the EPR cohort (TBR = 3.18 ± 1.74 vs 2.10 ± 0.92 respectively, p = 0.023). Tumor detection reached sensitivity and specificity scores of 0.82 and 0.93 for the angiography cohort and 0.66 and 0.90 for the EPR cohort, respectively (p = 0.1051 and p = 0.9099). DISCUSSION ICG administration timing during the angiography phase compared with the EPR phase improved TBR and diagnostic accuracy. Future work will focus on image pattern analysis and adaptation of the camera system to targeting fluorophores specific to breast cancer.
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Affiliation(s)
- Martha S Kedrzycki
- Hamlyn Centre, Institute of Global Health Innovation, Imperial College London, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK.,Department of Breast Surgery, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Maria Leiloglou
- Hamlyn Centre, Institute of Global Health Innovation, Imperial College London, London, UK. .,Department of Surgery and Cancer, Imperial College London, London, UK.
| | - Vadzim Chalau
- Hamlyn Centre, Institute of Global Health Innovation, Imperial College London, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - Nicolas Chiarini
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Paul T R Thiruchelvam
- Department of Surgery and Cancer, Imperial College London, London, UK.,Department of Breast Surgery, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Dimitri J Hadjiminas
- Department of Breast Surgery, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Katy R Hogben
- Department of Breast Surgery, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Faiza Rashid
- Department of Histopathology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Rathi Ramakrishnan
- Department of Histopathology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Ara W Darzi
- Hamlyn Centre, Institute of Global Health Innovation, Imperial College London, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - Daniel S Elson
- Hamlyn Centre, Institute of Global Health Innovation, Imperial College London, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - Daniel R Leff
- Hamlyn Centre, Institute of Global Health Innovation, Imperial College London, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK.,Department of Breast Surgery, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
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15
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Yun BL, Jang M, Ahn HS, Kim MY, Kim B, Kim SM. Using a mobile device for margin assessment of specimen mammography in breast-conserving surgery. Medicine (Baltimore) 2021; 100:e27243. [PMID: 34559124 PMCID: PMC8462545 DOI: 10.1097/md.0000000000027243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 08/27/2021] [Indexed: 11/25/2022] Open
Abstract
To compare the performance of margin assessment of specimen mammography (SM) in patients with breast-conserving surgery (BCS) on mobile devices and 5-megapixel (5M) thin film transistor liquid crystal display (TFT-LCD) monitors based on the safety margin for pathologic results.This retrospective study was approved by the institutional review board, and the requirement for informed consent was waived. A total of 105 consecutive breast cancer SM samples from 104 women who underwent BCS were included in the study. The SM were independently reviewed by two radiologists using mobile devices and by two additional radiologists using 5M TFT-LCD monitor. Each reader was asked to measure the shortest distance between the lesion and the lesion margin. The interpretation time was recorded. The sensitivity, specificity, and interobserver agreement were analyzed.In total, 19% (20/105) breast specimens had a positive surgical margin (<1 mm). The mean absolute difference from the pathologic margin was 0.60 ± 0.57 cm and 0.54 ± 0.47 cm using the 5 M TFT-LCD monitor and the mobile device, respectively (without any statistical significance, P = .273). The mean interpretation time was 49.5 and 47.6 s for the 5M TFT-LCD monitor and the mobile device, respectively (P = .012). The pooled sensitivity and specificity were 60% and 74% for 5M TFT-LCD monitor, and 60% and 69% for the mobile device (P = 1.00 and P = .190, respectively). The kappa coefficient indicated moderate agreement for both the displays.The diagnostic performance for margin assessment of SM in BCS patients on mobile devices and 5M TFT-LCD monitors are showed not statistically difference. The findings of the study provide evidence of the benefit of the mobile device for SM interpretation in patients who underwent BCS. However, a large sample size study is warranted before using a mobile device for margin evaluation on SM.The mobile device showed comparable diagnostic performance with 5M TFT-LCD monitor in the evaluation of SM margin in patients with BCS and could be used as a display tool for immediate assessment when a dedicated LCD monitor is unavailable.
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Affiliation(s)
- Bo La Yun
- Department of Radiology, Seoul National University Bunding Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Mijung Jang
- Department of Radiology, Seoul National University Bunding Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hye Shin Ahn
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Mi Young Kim
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Bohyoung Kim
- Division of Biomedical Engineering, Hankuk University of Foreign Studies, Seoul, Korea
| | - Sun Mi Kim
- Department of Radiology, Seoul National University Bunding Hospital, Seoul National University College of Medicine, Seongnam, Korea
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16
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Ellbrant J, Gulis K, Plasgård E, Svensjö T, Bendahl PO, Rydén L. Validated prediction model for positive resection margins in breast-conserving surgery based exclusively on preoperative data. BJS Open 2021; 5:6382014. [PMID: 34611702 PMCID: PMC8493005 DOI: 10.1093/bjsopen/zrab092] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 08/17/2021] [Indexed: 12/14/2022] Open
Abstract
Background Positive margins after breast-conserving surgery (BCS) and subsequent second surgery are associated with increased costs and patient discomfort. The aim of this study was to develop a prediction model for positive margins based on risk factors available before surgery. Methods Patients undergoing BCS for in situ or invasive cancer between 2015 and 2016 at site A formed a development cohort; those operated during 2017 in site A and B formed two validation cohorts. MRI was not used routinely. Preoperative radiographic and tumour characteristics and method of operation were collected from patient charts. Multivariable logistic regression was used to develop a prediction model for positive margins including variables with discriminatory capacity identified in a univariable model. The discrimination and calibration of the prediction model was assessed in the validation cohorts, and a nomogram developed. Results There were 432 patients in the development cohort, and 190 and 157 in site A and B validation cohorts respectively. Positive margins were identified in 77 patients (17.8 per cent) in the development cohort. A non-linear transformation of mammographic tumour size and six variables (visible on mammography, ductal carcinoma in situ, lobular invasive cancer, distance from nipple–areola complex, calcification, and type of surgery) were included in the final prediction model, which had an area under the curve of 0.80 (95 per cent c.i. 0.75 to 0.85). The discrimination and calibration of the prediction model was assessed in the validation cohorts, and a nomogram developed. Conclusion The prediction model showed good ability to predict positive margins after BCS and might, after further validation, be used before surgery in centres without the routine use of preoperative MRI. Presented in part to the San Antonio Breast Cancer Symposium, San Antonio, Texas, USA, December 2018 and the Swedish Surgical Society Annual Meeting, Helsingborg, Sweden, August 2018.
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Affiliation(s)
- J Ellbrant
- Department of Surgery, Skåne University Hospital, Malmö, Sweden.,Department of Clinical Sciences Lund, Division of Surgery, Lund University, Lund, Sweden
| | - K Gulis
- Department of Clinical Sciences Lund, Division of Surgery, Lund University, Lund, Sweden.,Department of Surgery, Kristianstad Central Hospital, Kristianstad, Sweden
| | - E Plasgård
- Department of Surgery, Skåne University Hospital, Lund, Sweden
| | - T Svensjö
- Department of Surgery, Kristianstad Central Hospital, Kristianstad, Sweden
| | - P O Bendahl
- Department of Clinical Sciences Lund, Division of Oncology and Pathology, Lund University, Lund, Sweden
| | - L Rydén
- Department of Clinical Sciences Lund, Division of Surgery, Lund University, Lund, Sweden.,Department of Surgery, Skåne University Hospital, Lund, Sweden
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17
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Keelan S, Flanagan M, Hill ADK. Evolving Trends in Surgical Management of Breast Cancer: An Analysis of 30 Years of Practice Changing Papers. Front Oncol 2021; 11:622621. [PMID: 34422626 PMCID: PMC8371403 DOI: 10.3389/fonc.2021.622621] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 04/19/2021] [Indexed: 01/12/2023] Open
Abstract
The management of breast cancer has evolved into a multidisciplinary evidence-based surgical speciality, with emphasis on conservative surgery. A number of landmark trials have established lumpectomy followed by radiation as the standard of care for many patients. The aim of this study is to construct a narrative review of recent developments in the surgical management of breast cancer and how such developments have impacted surgical practice. A comprehensive literature search of Pubmed was conducted. The latest search was performed on October 31st, 2020. Search terms “breast cancer” were used in combinations with specific key words and Boolean operators relating to surgical management. The reference lists of retrieved articles were comprehensively screened for additional eligible publications. Articles were selected and reviewed based on relevance. We selected publications in the past 10 years but did not exclude commonly referenced and highly regarded previous publications. Review articles and book chapters were also cited to provide reference on details not discussed in the academic literature. This article reviews the current evidence in surgical management of early-stage breast cancer, discusses recent trends in surgical practice for therapeutic and prophylactic procedures and provides commentary on implications and factors associated with these trends.
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Affiliation(s)
- Stephen Keelan
- The Department of Surgery, The Royal College of Surgeons in Ireland, Dublin, Ireland.,The Department of Surgery, Beaumont Hospital, Dublin, Ireland
| | - Michael Flanagan
- The Department of Surgery, The Royal College of Surgeons in Ireland, Dublin, Ireland.,The Department of Surgery, Beaumont Hospital, Dublin, Ireland
| | - Arnold D K Hill
- The Department of Surgery, The Royal College of Surgeons in Ireland, Dublin, Ireland.,The Department of Surgery, Beaumont Hospital, Dublin, Ireland
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18
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Lizio MG, Boitor R, Notingher I. Selective-sampling Raman imaging techniques for ex vivo assessment of surgical margins in cancer surgery. Analyst 2021; 146:3799-3809. [PMID: 34042924 DOI: 10.1039/d1an00296a] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
One of the main challenges in cancer surgery is to ensure the complete excision of the tumour while sparing as much healthy tissue as possible. Histopathology, the gold-standard technique used to assess the surgical margins on the excised tissue, is often impractical for intra-operative use because of the time-consuming tissue cryo-sectioning and staining, and availability of histopathologists to assess stained tissue sections. Raman micro-spectroscopy is a powerful technique that can detect microscopic residual tumours on ex vivo tissue samples with accuracy, based entirely on intrinsic chemical differences. However, raster-scanning Raman micro-spectroscopy is a slow imaging technique that typically requires long data acquisition times wich are impractical for intra-operative use. Selective-sampling Raman imaging overcomes these limitations by using information regarding the spatial properties of the tissue to reduce the number of Raman spectra. This paper reviews the latest advances in selective-sampling Raman techniques and applications, mainly based on multimodal optical imaging. We also highlight the latest results of clinical integration of a prototype device for non-melanoma skin cancer. These promising results indicate the potential impact of Raman spectroscopy for providing fast and objective assessment of surgical margins, helping surgeons ensure the complete removal of tumour cells while sparing as much healthy tissue as possible.
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Affiliation(s)
- Maria Giovanna Lizio
- School of Physics and Astonomy, University of Nottingham, Nottingham, Nottinghamshire, UK.
| | - Radu Boitor
- School of Physics and Astonomy, University of Nottingham, Nottingham, Nottinghamshire, UK.
| | - Ioan Notingher
- School of Physics and Astonomy, University of Nottingham, Nottingham, Nottinghamshire, UK.
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19
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Struik GM, Schermers B, Mares I, Lont HE, Bradshaw JW, Ten Haken B, Ruers TJM, Mourik JEM, Birnie E, Klem TMAL. Randomized controlled trial comparing magnetic marker localization (MaMaLoc) with wire-guided localization in the treatment of early-stage breast cancer. Breast J 2021; 27:638-650. [PMID: 34142409 DOI: 10.1111/tbj.14262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/23/2021] [Accepted: 05/24/2021] [Indexed: 11/29/2022]
Abstract
Wire-guided localization (WGL) is the standard of care in the surgical treatment of nonpalpable breast tumors. In this study, we compare the use of a new magnetic marker localization (MaMaLoc) technique to WGL in the treatment of early-stage breast cancer patients. Open-label, single-center, randomized controlled trial comparing MaMaLoc (intervention) to WGL (control) in women with early-stage breast cancer. Primary outcome was surgical usability measured using the System Usability Scale (SUS, 0-100 score). Secondary outcomes were patient reported, clinical, and pathological outcomes such as retrieval rate, operative time, resected specimen weight, margin status, and reoperation rate. Thirty-two patients were analyzed in the MaMaLoc group and 35 in the WGL group. Patient and tumor characteristics were comparable between groups. No in situ complications occurred. Retrieval rate was 100% in both groups. Surgical usability was higher for MaMaLoc: 70.2 ± 8.9 vs. 58.1 ± 9.1, p < 0.001. Patients reported higher overall satisfaction with MaMaLoc (median score 5/5) versus WGL (score 4/5), p < 0.001. The use of magnetic marker localization (MaMaLoc) for early-stage breast cancer is effective and has higher surgical usability than standard WGL.
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Affiliation(s)
- Gerson M Struik
- Department of Surgery, Franciscus Gasthuis and Vlietland, Rotterdam, The Netherlands
| | - Bram Schermers
- Department of Surgery, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Ingeborg Mares
- Department of Surgery, Franciscus Gasthuis and Vlietland, Rotterdam, The Netherlands
| | - Harold E Lont
- Department of Surgery, Franciscus Gasthuis and Vlietland, Rotterdam, The Netherlands
| | - Jennifer W Bradshaw
- Department of Radiology, Franciscus Gasthuis and Vlietland, Rotterdam, The Netherlands
| | - Bernard Ten Haken
- Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Theo J M Ruers
- Department of Surgery, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Jurgen E M Mourik
- Department of Medical Physics, Franciscus Gasthuis and Vlietland, Rotterdam, The Netherlands
| | - Erwin Birnie
- Department of Statistics and Education, Franciscus Gasthuis and Vlietland, Rotterdam, The Netherlands.,Department of Genetics, University Medical Centre Groningen, University of Groningen, Amsterdam, The Netherlands
| | - Taco M A L Klem
- Department of Surgery, Franciscus Gasthuis and Vlietland, Rotterdam, The Netherlands
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20
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Gonzalez-Woge MA, Martin-Tellez KS, Gonzalez-Woge R, Teran-De-la-Sancha K, de la Rosa-Abaroa M, Garcia-Cardenas FJ, Munguia-Garza P, Cervantes-Delgado P, Garcia-Tapia Prandiz LR, Mangwani-Mordani S, Esparza-Arias N, Bargallo-Rocha JE. Inadequate prediction of postoperative complications in breast cancer surgery: An evaluation of the ACS Surgical Risk Calculator. J Surg Oncol 2021; 124:483-491. [PMID: 34028818 DOI: 10.1002/jso.26529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/05/2021] [Accepted: 05/03/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND The American College of Surgeon (ACS) Surgical Risk Calculator is an online tool that helps surgeons estimate the risk of postoperative complications for numerous surgical procedures across several surgical specialties. METHODS We evaluated the predictive performance of the calculator in 385 cancer patients undergoing breast surgery. Calculator-predicted complication rates were compared with observed complication rates; calculator performance was evaluated using calibration and discrimination analyses. RESULTS The mean calculator-predicted rates for any complication (4.1%) and serious complication (3.2%) were significantly lower than the observed rates (11.2% and 5.2%, respectively). The area under the curve was 0.617 for any complication and 0.682 for serious complications. p Values for the Hosmer-Lemeshow test were significant (<.05) for both outcomes. Brier scores were 0.102 for any complication and 0.048 for serious complication. CONCLUSIONS The ACS risk calculator is not an ideal tool for predicting individual risk of complications following breast surgery in a Mexican cohort. The most valuable use of the calculator may reside in its role as an aid for patient-led surgery planning. The possibility of introducing breast surgery-specific data could improve the performance of the calculator. Furthermore, a disease-specific calculator could provide more accurate predictions and include complications more frequently found in breast cancer surgery.
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Affiliation(s)
| | | | | | - Kevin Teran-De-la-Sancha
- Department of Hematology and Oncology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, México
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21
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Cassar Q, Caravera S, MacGrogan G, Bücher T, Hillger P, Pfeiffer U, Zimmer T, Guillet JP, Mounaix P. Terahertz refractive index-based morphological dilation for breast carcinoma delineation. Sci Rep 2021; 11:6457. [PMID: 33742042 PMCID: PMC7979939 DOI: 10.1038/s41598-021-85853-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/05/2021] [Indexed: 11/08/2022] Open
Abstract
This paper reports investigations led on the combination of the refractive index and morphological dilation to enhance performances towards breast tumour margin delineation during conserving surgeries. The refractive index map of invasive ductal and lobular carcinomas were constructed from an inverse electromagnetic problem. Morphological dilation combined with refractive index thresholding was conducted to classify the tissue regions as malignant or benign. A histology routine was conducted to evaluate the performances of various dilation geometries associated with different thresholds. It was found that the combination of a wide structuring element and high refractive index was improving the correctness of tissue classification in comparison to other configurations or without dilation. The method reports a sensitivity of around 80% and a specificity of 82% for the best case. These results indicate that combining the fundamental optical properties of tissues denoted by their refractive index with morphological dilation may open routes to define supporting procedures during breast-conserving surgeries.
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Affiliation(s)
- Quentin Cassar
- Integration from Material to Systems Laboratory, University of Bordeaux, 33405, Talence, France
| | - Samuel Caravera
- Department of Pathology, Bergonié Institute, 33076, Bordeaux, France
| | - Gaëtan MacGrogan
- Department of Pathology, Bergonié Institute, 33076, Bordeaux, France
| | - Thomas Bücher
- Institute for High-Frequency and Communication Technology, University of Wuppertal, 42119, Wuppertal, Germany
| | - Philipp Hillger
- Institute for High-Frequency and Communication Technology, University of Wuppertal, 42119, Wuppertal, Germany
| | - Ullrich Pfeiffer
- Institute for High-Frequency and Communication Technology, University of Wuppertal, 42119, Wuppertal, Germany
| | - Thomas Zimmer
- Integration from Material to Systems Laboratory, University of Bordeaux, 33405, Talence, France
| | - Jean-Paul Guillet
- Integration from Material to Systems Laboratory, University of Bordeaux, 33405, Talence, France
| | - Patrick Mounaix
- Integration from Material to Systems Laboratory, University of Bordeaux, 33405, Talence, France.
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22
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Foo KY, Kennedy KM, Zilkens R, Allen WM, Fang Q, Sanderson RW, Anstie J, Dessauvagie BF, Latham B, Saunders CM, Chin L, Kennedy BF. Optical palpation for tumor margin assessment in breast-conserving surgery. BIOMEDICAL OPTICS EXPRESS 2021; 12:1666-1682. [PMID: 33796380 PMCID: PMC7984801 DOI: 10.1364/boe.415888] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 01/22/2021] [Accepted: 01/25/2021] [Indexed: 06/12/2023]
Abstract
Intraoperative margin assessment is needed to reduce the re-excision rate of breast-conserving surgery. One possibility is optical palpation, a tactile imaging technique that maps stress (force applied across the tissue surface) as an indicator of tissue stiffness. Images (optical palpograms) are generated by compressing a transparent silicone layer on the tissue and measuring the layer deformation using optical coherence tomography (OCT). This paper reports, for the first time, the diagnostic accuracy of optical palpation in identifying tumor within 1 mm of the excised specimen boundary using an automated classifier. Optical palpograms from 154 regions of interest (ROIs) from 71 excised tumor specimens were obtained. An automated classifier was constructed to predict the ROI margin status by first choosing a circle diameter, then searching for a location within the ROI where the circle was ≥ 75% filled with high stress (indicating a positive margin). A range of circle diameters and stress thresholds, as well as the impact of filtering out non-dense tissue regions, were tested. Sensitivity and specificity were calculated by comparing the automated classifier results with the true margin status, determined from co-registered histology. 83.3% sensitivity and 86.2% specificity were achieved, compared to 69.0% sensitivity and 79.0% specificity obtained with OCT alone on the same dataset using human readers. Representative optical palpograms show that positive margins containing a range of cancer types tend to exhibit higher stress compared to negative margins. These results demonstrate the potential of optical palpation for margin assessment.
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Affiliation(s)
- Ken Y. Foo
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, Australia
- The University of Western Australia, Perth, Australia
- Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Australia
| | - Kelsey M. Kennedy
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, Australia
- The University of Western Australia, Perth, Australia
| | - Renate Zilkens
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, Australia
- The University of Western Australia, Perth, Australia
- School of Medicine, The University of Western Australia, Perth, Australia
| | - Wes M. Allen
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, Australia
- The University of Western Australia, Perth, Australia
- Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Australia
| | - Qi Fang
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, Australia
- The University of Western Australia, Perth, Australia
- Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Australia
| | - Rowan W. Sanderson
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, Australia
- The University of Western Australia, Perth, Australia
- Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Australia
| | - James Anstie
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, Australia
- The University of Western Australia, Perth, Australia
- Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Australia
| | - Benjamin F. Dessauvagie
- School of Medicine, The University of Western Australia, Perth, Australia
- PathWest, Fiona Stanley Hospital, Murdoch, Australia
| | - Bruce Latham
- PathWest, Fiona Stanley Hospital, Murdoch, Australia
- School of Medicine, University of Notre Dame, Fremantle, Australia
| | - Christobel M. Saunders
- School of Medicine, The University of Western Australia, Perth, Australia
- Breast Centre, Fiona Stanley Hospital, Murdoch, Australia
- Breast Clinic, Royal Perth Hospital, Perth, Australia
| | - Lixin Chin
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, Australia
- The University of Western Australia, Perth, Australia
- Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Australia
| | - Brendan F. Kennedy
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, Australia
- The University of Western Australia, Perth, Australia
- Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Australia
- Australian Research Council Centre for Personalised Therapeutics Technologies, Perth, Australia
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23
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Retrospective Review of Preoperative Radiofrequency Tag Localization of Breast Lesions in 848 Patients. AJR Am J Roentgenol 2020; 217:605-612. [PMID: 33084384 DOI: 10.2214/ajr.20.24374] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND. Advantages of radiofrequency tags for preoperative breast lesion localization include decoupling of tag placement from surgical schedules and improved patient comfort. OBJECTIVE. The purpose of this study was to evaluate the feasibility of a preoperative localization radiofrequency tag system for breast lesions requiring surgical excision. METHODS. The cohort for this retrospective study included consecutive patients who underwent image-guided needle localization with radiofrequency tags before surgical excision from July 12, 2018, to July 31, 2019. Images and medical records were reviewed to evaluate the pathologic diagnoses serving as indications for tag placement, imaging guidance for tag placement, number of tags placed, and target lesion type. Tag placement technical accuracy rate (defined as deployment of the tag within 1 cm of the edge of the target), success (defined as technical accuracy without complication), and surgical margin and reexcision status were evaluated. RESULTS. A total of 1013 tags were placed under imaging guidance in 848 patients (mean age, 60 years; range, 23-96 years) and 847 subsequently underwent surgical excision. Tags were most commonly placed for invasive carcinoma (537/1013, 53.0%), ductal carcinoma in situ (138/1013, 13.6%), and high-risk lesions (289/1013, 28.5%). A total of 673 (66.4%) tags were deployed under mammographic guidance, whereas 340 (33.6%) were placed under sonographic guidance. Two or more tags were placed in 149 of 848 patients (17.6%). Targeted lesion types primarily included masses (448/1013, 44.2%), biopsy clip markers (331/1013, 32.7%), and calcifications (155/1013, 15.3%). Technical accuracy of placement was achieved in 1004 (99.1%) tags. Of the nine inaccurate tag placements, seven (77.8%) required an additional tag or wire placement. Seven (0.7%) biopsy clip markers were displaced within the breast or removed by the tag device during placement. No complications were reported intraoperatively. Therefore, success was achieved in 997 (98.4%) tags. Tags were successfully retrieved in all 847 patients who underwent surgery. Of the 568 patients with a preoperative diagnosis of carcinoma, 86 (15.1%) had positive or close surgical margins requiring surgical reexcision. CONCLUSION. Preoperative image-guided localization with radiofrequency tags is a safe and feasible technique for breast lesions requiring surgery. CLINICAL IMPACT. Radiofrequency tag localization is an acceptable alternative to needle or wire localization, offering the potential for improved patient workflow and experience.
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24
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Cullinane CM, Byrne J, Akmenkalne L, O’ Leary DP, Connors AM, Corrigan MA, Redmond HP, Kelly L, O’ Sullivan MJ. The LOCalizer Radiofrequency Identification System: An Effective New Technology for Localizing Non-Palpable Breast Lesions for Surgery. Surg Innov 2020; 28:473-478. [DOI: 10.1177/1553350620967853] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background. Breast screening has decreased morbidity and mortality due to detection of early, non-palpable breast cancers. One of the challenges of performing breast-conserving surgery on non-palpable breast tumours is accurate localization of the cancer. We aimed to perform a feasibility study to examine the outcomes associated with the introduction of a novel radiofrequency identification system (RFID) called LOCalizer as an alternative to traditional wire-guided localization. Methods. Data were prospectively collected on all patients undergoing breast-conserving surgery using the LOCalizer RFID system in a regional cancer centre between July 2019 and March 2020. Patients had a RFID tag placed preoperatively and underwent surgical removal of the tag with the index lesion guided by a handheld LOCalizer probe. The primary aim was successful placement and retrieval of the RFID tag. Re-excision rates, specimen size, specimen weight, cancer subtype and complication rate were all recorded. Results. Sixty-nine patients aged between 50 and 69 years had a LOCalizer tag inserted between July 2019 and March 2020. Of these, 6 (8.7%) were diagnostic and 63 (91.3%) were therapeutic. There was no migration of RFID tags, and all tags were retrieved with the index lesion. The overall re-excision of margin rate was 17.4% (12/69). All re-excision of margins was due to positive radial margins. The overall complication rate was 1.4% with one grade 1 Clavien-Dindo morbidity. Conclusion. The LOCalizer RFID is an effective and safe wire-free localization method for non-palpable breast lesions.
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Affiliation(s)
| | - James Byrne
- Department of Breast Surgery, Cork University Hospital, Ireland
| | - Liga Akmenkalne
- Department of Breast Surgery, Cork University Hospital, Ireland
| | - Donal P. O’ Leary
- Department of Breast Surgery, Cork University Hospital, Ireland
- Cork Breast Research Centre, University of College Cork, Ireland
| | | | - Mark A. Corrigan
- Department of Breast Surgery, Cork University Hospital, Ireland
- Cork Breast Research Centre, University of College Cork, Ireland
| | - Henry Paul Redmond
- Department of Breast Surgery, Cork University Hospital, Ireland
- Cork Breast Research Centre, University of College Cork, Ireland
| | - Louise Kelly
- Department of Breast Surgery, Cork University Hospital, Ireland
- Southern Unit, BreastCheck Screening Service, Cork, Ireland
| | - Martin J. O’ Sullivan
- Department of Breast Surgery, Cork University Hospital, Ireland
- Southern Unit, BreastCheck Screening Service, Cork, Ireland
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25
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Nunez A, Jones V, Schulz-Costello K, Schmolze D. Accuracy of gross intraoperative margin assessment for breast cancer: experience since the SSO-ASTRO margin consensus guidelines. Sci Rep 2020; 10:17344. [PMID: 33060797 PMCID: PMC7567822 DOI: 10.1038/s41598-020-74373-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 09/30/2020] [Indexed: 12/28/2022] Open
Abstract
Gross intraoperative assessment can be used to ensure negative margins at the time of surgery. Previous studies of this technique were conducted before the introduction of consensus guidelines defining a “positive” margin. We performed a retrospective study examining the accuracy of this technique since these guidelines were published. We identified all specimens that were grossly examined at the time of breast conserving surgery from January 2014 to July 2020. Gross and final microscopic diagnoses were compared and the performance of intraoperative examination was assessed in terms of false positive and false negative rates. Logistic regression models were used to examine the effect of clinicopathologic covariates on discordance. 327 cases were reviewed. Gross exam prompted re-excision in 166 cases (61%). The rate of false negative discordance was 8.6%. In multivariate analysis, multifocality on final pathology was associated with discordance. We consider the false negative rate acceptable for routine clinical use; however, there is an ongoing need for more accurate methods for the intraoperative assessment of margins.
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Affiliation(s)
- Alberto Nunez
- Beckman Research Institute, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA, 91010, USA
| | - Veronica Jones
- Department of Surgery, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA, 91010, USA
| | - Katherine Schulz-Costello
- Department of Surgery, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA, 91010, USA
| | - Daniel Schmolze
- Department of Pathology, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA, 91010, USA.
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26
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Kennedy KM, Zilkens R, Allen WM, Foo KY, Fang Q, Chin L, Sanderson RW, Anstie J, Wijesinghe P, Curatolo A, Tan HEI, Morin N, Kunjuraman B, Yeomans C, Chin SL, DeJong H, Giles K, Dessauvagie BF, Latham B, Saunders CM, Kennedy BF. Diagnostic Accuracy of Quantitative Micro-Elastography for Margin Assessment in Breast-Conserving Surgery. Cancer Res 2020; 80:1773-1783. [PMID: 32295783 DOI: 10.1158/0008-5472.can-19-1240] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 08/09/2019] [Accepted: 02/14/2020] [Indexed: 01/16/2023]
Abstract
Inadequate margins in breast-conserving surgery (BCS) are associated with an increased likelihood of local recurrence of breast cancer. Currently, approximately 20% of BCS patients require repeat surgery due to inadequate margins at the initial operation. Implementation of an accurate, intraoperative margin assessment tool may reduce this re-excision rate. This study determined, for the first time, the diagnostic accuracy of quantitative micro-elastography (QME), an optical coherence tomography (OCT)-based elastography technique that produces images of tissue microscale elasticity, for detecting tumor within 1 mm of the margins of BCS specimens. Simultaneous OCT and QME were performed on the margins of intact, freshly excised specimens from 83 patients undergoing BCS and on dissected specimens from 7 patients undergoing mastectomy. The resulting three-dimensional images (45 × 45 × 1 mm) were coregistered with postoperative histology to determine tissue types present in each scan. Data from 12 BCS patients and the 7 mastectomy patients served to build a set of images for reader training. One hundred and fifty-four subimages (10 × 10 × 1 mm) from the remaining 71 BCS patients were included in a blinded reader study, which resulted in 69.0% sensitivity and 79.0% specificity using OCT images, versus 92.9% sensitivity and 96.4% specificity using elasticity images. The quantitative nature of QME also facilitated development of an automated reader, which resulted in 100.0% sensitivity and 97.7% specificity. These results demonstrate high accuracy of QME for detecting tumor within 1 mm of the margin and the potential for this technique to improve outcomes in BCS. SIGNIFICANCE: An optical imaging technology probes breast tissue elasticity to provide accurate assessment of tumor margin involvement in breast-conserving surgery.
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Affiliation(s)
- Kelsey M Kennedy
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, and Centre for Medical Research, The University of Western Australia, Perth, Australia
| | - Renate Zilkens
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, and Centre for Medical Research, The University of Western Australia, Perth, Australia.,School of Medicine, The University of Western Australia, Perth, Australia
| | - Wes M Allen
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, and Centre for Medical Research, The University of Western Australia, Perth, Australia.,Department of Electrical, Electronic & Computer Engineering, School of Engineering, The University of Western Australia, Perth, Australia
| | - Ken Y Foo
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, and Centre for Medical Research, The University of Western Australia, Perth, Australia.,Department of Electrical, Electronic & Computer Engineering, School of Engineering, The University of Western Australia, Perth, Australia
| | - Qi Fang
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, and Centre for Medical Research, The University of Western Australia, Perth, Australia.,Department of Electrical, Electronic & Computer Engineering, School of Engineering, The University of Western Australia, Perth, Australia
| | - Lixin Chin
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, and Centre for Medical Research, The University of Western Australia, Perth, Australia.,Department of Electrical, Electronic & Computer Engineering, School of Engineering, The University of Western Australia, Perth, Australia
| | - Rowan W Sanderson
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, and Centre for Medical Research, The University of Western Australia, Perth, Australia.,Department of Electrical, Electronic & Computer Engineering, School of Engineering, The University of Western Australia, Perth, Australia
| | - James Anstie
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, and Centre for Medical Research, The University of Western Australia, Perth, Australia.,Department of Electrical, Electronic & Computer Engineering, School of Engineering, The University of Western Australia, Perth, Australia
| | - Philip Wijesinghe
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, and Centre for Medical Research, The University of Western Australia, Perth, Australia.,Department of Electrical, Electronic & Computer Engineering, School of Engineering, The University of Western Australia, Perth, Australia
| | - Andrea Curatolo
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, and Centre for Medical Research, The University of Western Australia, Perth, Australia.,Department of Electrical, Electronic & Computer Engineering, School of Engineering, The University of Western Australia, Perth, Australia
| | - Hsern Ern I Tan
- School of Medicine, The University of Western Australia, Perth, Australia
| | | | | | - Chris Yeomans
- PathWest, Fiona Stanley Hospital, Murdoch, Australia
| | - Synn Lynn Chin
- Breast Centre, Fiona Stanley Hospital, Murdoch, Australia
| | - Helen DeJong
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, and Centre for Medical Research, The University of Western Australia, Perth, Australia
| | | | - Benjamin F Dessauvagie
- School of Medicine, The University of Western Australia, Perth, Australia.,PathWest, Fiona Stanley Hospital, Murdoch, Australia
| | - Bruce Latham
- PathWest, Fiona Stanley Hospital, Murdoch, Australia
| | - Christobel M Saunders
- School of Medicine, The University of Western Australia, Perth, Australia.,Breast Centre, Fiona Stanley Hospital, Murdoch, Australia.,Breast Clinic, Royal Perth Hospital, Perth, Australia
| | - Brendan F Kennedy
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, and Centre for Medical Research, The University of Western Australia, Perth, Australia. .,Department of Electrical, Electronic & Computer Engineering, School of Engineering, The University of Western Australia, Perth, Australia
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27
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Tamburelli F, Maggiorotto F, Marchiò C, Balmativola D, Magistris A, Kubatzki F, Sgandurra P, Di Virgilio MR, Regge D, Montemurro F, Gatti M, Sapino A, Ponzone R. Reoperation rate after breast conserving surgery as quality indicator in breast cancer treatment: A reappraisal. Breast 2020; 53:181-188. [PMID: 32841804 PMCID: PMC7451417 DOI: 10.1016/j.breast.2020.07.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 07/04/2020] [Accepted: 07/28/2020] [Indexed: 12/15/2022] Open
Abstract
Aim To analyse the role of repeated breast surgery (RBS) after breast conserving surgery (BCS) as a quality indicator in a consecutive series of breast cancer patients. Methods Data from 1233 breast cancer patients submitted to BCS from 2015 to 2019 were reviewed. The influence of several variables on RBS rate (182/1232; 14.8%) was examined. Univariate and multivariate analyses were conducted to look for significant associations with the risk of RBS. Results Surgical workload, BCS rate and clinicopathological variables were consistent over the study period, while RBS rate decreased after the introduction of shaving of cavity margins (from 17.9% to 9.5%). Tumor persistence at RBS was higher for mastectomy vs. re-excision (87.3% vs. 37.8%; p = 0.05), inconclusive vs. positive diagnostic biopsy (48.2% vs. 69.4%; p = 0.003), ductal carcinoma in situ vs. invasive carcinoma (69.0% vs. 51.3%; p = 0.046) and lower after neoadjuvant therapy (14.3% vs. 57.8%; p = 0.044). Several clinicopathological variables were associated with the risk of RBS, but only multifocality [Odds Ratio (OR): 1.8; p = 0.009], microcalcifications (OR: 2.0, p = 0.000), neoadjuvant therapy (OR: 0.4; p = 0.014), pathological intraoperative assessment (OR: 0.6; p = 0.010) and shaving of cavity margins (OR: 0.3; p = 0.000) retained independent value at multivariate analysis. Conclusions RBS rate can be reduced by shaving of cavity margins. Current standards for RBS should not be made more stringent due to the existence of non-actionable risk factors. The value of RBS as a quality indicator should be scrutinzed. Some breast cancer patients need a reoperation for incomplete tumor excision after breast conserving surgery. Reoperation rates show wide variations (10%–50%) among different Countries. Shaving of cavity margins may reduce the reoperation rate, but non-invasive and multicentric lesiona are non-actionable risk factors The value of reoperation rate as a quality indicator of breast cancer surgery is questionable.
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Affiliation(s)
- Francesca Tamburelli
- Gynecological Oncology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy
| | - Furio Maggiorotto
- Gynecological Oncology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy
| | - Caterina Marchiò
- Pathology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy; Department of Medical Sciences, University of Turin, 10126, Turin, Italy
| | - Davide Balmativola
- Pathology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy
| | - Alessandra Magistris
- Gynecological Oncology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy
| | - Franziska Kubatzki
- Gynecological Oncology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy
| | - Paola Sgandurra
- Gynecological Oncology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy
| | - Maria Rosaria Di Virgilio
- Radiology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy
| | - Daniele Regge
- Department of Surgical Sciences, University of Turin, 10124, Turin, Italy; Radiology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy
| | - Filippo Montemurro
- Multidisciplinary Outpatient Oncology Clinic, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy
| | - Marco Gatti
- Radiotherapy Unit, Candiolo Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy
| | - Anna Sapino
- Pathology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy; Department of Medical Sciences, University of Turin, 10126, Turin, Italy
| | - Riccardo Ponzone
- Gynecological Oncology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy.
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28
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Tasdöven I, Karadeniz Çakmak G, Emre AU, Engin H, Bahadır B, Bakkal HB, Güllüoğlu MB. Intraoperative ultrasonography-guided surgery: An effective modality for breast conservation after neo-adjuvant chemotherapy. Breast J 2020; 26:1680-1687. [PMID: 33443786 DOI: 10.1111/tbj.13992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 06/05/2020] [Accepted: 07/10/2020] [Indexed: 11/28/2022]
Abstract
Margin status is one of the significant prognostic factors for recurrence in breast-conserving surgery (BCS). The issue that merits consideration for oncologic safety and cost-effectiveness about the modalities to assure clear margins at initial surgical intervention remains controversial after neo-adjuvant chemotherapy (NAC). The presented study aimed to assess the impact of intraoperative ultrasound (IOUS)-guided surgery on accurate localization of tumor site, adequacy of excision with clear margins, and healthy tissue sacrifice in BCS after NAC. Patients who had IOUS-guided BCS ater NAC were reviewed. No patient had preoperative localization with wire or radiotracer. Intraoperative real-time sonographic localization, sonographic margin assessment during resection, macroscopic and sonographic examination of specimen, and cavity shavings (CS) were done as the standard procedure. No frozen assessment was performed. One hundred ninety-four patients were included, in which 42.5% had pCR. IOUS-guided surgery accomplished successful localization of the targeted lesions in all patients. Per protocol, all inked margins on CS specimens were reported to be tumor-free in permanent histopathology. No re-excision or mastectomy was required. For a setting without CS, the negative predictive value (NPV) of IOUS rate was 96%. IOUS was found to over and underestimate tumor response to NAC both in 2% of patients. IOUS-guided surgery seems to be an efficient modality to perform adequate BCS after NAC with no additional localization method. Especially, when CS is integrated as a standard to BCS, IOUS seems to provide safe surgery for patients with no false negativity and a high rate of NPV.
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Affiliation(s)
- Ilhan Tasdöven
- Department of Surgery, The School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | - Güldeniz Karadeniz Çakmak
- Department of Surgery, The School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | - Ali Ugur Emre
- Department of Surgery, The School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | - Hüseyin Engin
- Department of Oncology, The School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | - Burak Bahadır
- Department of Pathology, The School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | - Hakan Bekir Bakkal
- Department of Radiation Oncology, The School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
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Racz JM, Glasgow AE, Keeney GL, Degnim AC, Hieken TJ, Jakub JW, Cheville JC, Habermann EB, Boughey JC. Intraoperative Pathologic Margin Analysis and Re-Excision to Minimize Reoperation for Patients Undergoing Breast-Conserving Surgery. Ann Surg Oncol 2020; 27:5303-5311. [PMID: 32623609 DOI: 10.1245/s10434-020-08785-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Reoperation rates following breast-conserving surgery (BCS) range from 10 to 40%, with marked surgeon and institutional variation. OBJECTIVE The aim of this study was to identify factors associated with intraoperative margin re-excision, evaluate for any differences in local recurrence based on margin re-excision and determine reoperation rates with use of intraoperative margin analysis. PATIENTS AND METHODS We analyzed consecutive patients with ductal carcinoma in situ (DCIS) or invasive breast cancer who underwent BCS at our institution between 1 January 2005 and 31 December 2016. Routine intraoperative frozen section margin analysis was performed and positive or close margins were re-excised intraoperatively. Univariate analysis was used to compare margin status and the Kaplan-Meier method was used to compare recurrence. Multivariable logistic regression was utilized to analyze factors associated with re-excision. RESULTS We identified 3201 patients who underwent BCS-688 for DCIS and 2513 for invasive carcinoma. Overall, 1513 (60.2%) patients with invasive cancer and 434 (63.1%) patients with DCIS had close or positive margins that underwent intraoperative re-excision. Margin re-excision was associated with larger tumor size in both groups. The permanent pathology positive margin rate among all patients was 1.2%, and the 30-day reoperation rate for positive margins was 1.1%. Five-year local recurrence rates were 0.6% and 1.2% for patients with DCIS and invasive cancer, respectively. There was no difference in recurrence between patients with and without intraoperative margin re-excision (p = 0.92). CONCLUSION Both DCIS and invasive carcinoma had similar rates of intraoperative margin re-excision. Although intraoperative margin re-excision was common, the reoperation rate was extremely low and there was no difference in recurrence between those with or without intraoperative re-excision.
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Affiliation(s)
| | - Amy E Glasgow
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Program, Mayo Clinic, Rochester, MN, USA
| | - Gary L Keeney
- Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA
| | - Amy C Degnim
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Tina J Hieken
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - James W Jakub
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - John C Cheville
- Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth B Habermann
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Program, Mayo Clinic, Rochester, MN, USA
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30
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Tamburelli F, Ponzone R. The Value of Repeated Breast Surgery as a Quality Indicator in Breast Cancer Care. Ann Surg Oncol 2020; 28:340-352. [PMID: 32524463 DOI: 10.1245/s10434-020-08704-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Indexed: 02/06/2023]
Abstract
Breast-conserving surgery, a major achievement in surgical oncology, has allowed an increasing number of breast cancer patients to avoid the mutilation of mastectomy. However, mastectomy still is performed in certain circumstances although breast-conserving surgery would be equally safe. Many reasons, including patients' and surgeons' personal motivations, influence the decision-making process before the final choice between breast preservation and mastectomy. The importance of quality measurement and reporting in medicine is increasingly recognized, and breast surgery is no exception. The substantial variability of re-excision rates for positive surgical margins after a first attempt at breast-conserving surgery suggests that improvement is possible. Therefore, the re-excision rate has been proposed as a quality metric for assessing and comparing the performance of different institutions. Indeed, re-excision rates can be reduced by actionable factors such as accurate preoperative local staging, localization of occult lesions, and intraoperative assessment of the oriented specimen. However, equally important non-actionable risk factors pertaining the biology, detectability, and resectability of the tumor also should be taken into account. Therefore, if the re-excision rate has to be used as a performance indicator of breast surgical care, critical interpretation of results with accurate case-mix adjustment are mandatory, and reasonable targets must be appropriately set so that surgeons treating patients at higher risk of positive margins are not unduly penalized.
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Affiliation(s)
- Francesca Tamburelli
- Gynecological Oncology Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy
| | - Riccardo Ponzone
- Gynecological Oncology Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy.
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31
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Foo KY, Chin L, Zilkens R, Lakhiani DD, Fang Q, Sanderson R, Dessauvagie BF, Latham B, McLaren S, Saunders CM, Kennedy BF. Three-dimensional mapping of the attenuation coefficient in optical coherence tomography to enhance breast tissue microarchitecture contrast. JOURNAL OF BIOPHOTONICS 2020; 13:e201960201. [PMID: 32141243 DOI: 10.1002/jbio.201960201] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 02/16/2020] [Accepted: 03/04/2020] [Indexed: 06/10/2023]
Abstract
Effective intraoperative tumor margin assessment is needed to reduce re-excision rates in breast-conserving surgery (BCS). Mapping the attenuation coefficient in optical coherence tomography (OCT) throughout a sample to create an image (attenuation imaging) is one promising approach. For the first time, three-dimensional OCT attenuation imaging of human breast tissue microarchitecture using a wide-field (up to ~45 × 45 × 3.5 mm) imaging system is demonstrated. Representative results from three mastectomy and one BCS specimen (from 31 specimens) are presented with co-registered postoperative histology. Attenuation imaging is shown to provide substantially improved contrast over OCT, delineating nuanced features within tumors (including necrosis and variations in tumor cell density and growth patterns) and benign features (such as sclerosing adenosis). Additionally, quantitative micro-elastography (QME) images presented alongside OCT and attenuation images show that these techniques provide complementary contrast, suggesting that multimodal imaging could increase tissue identification accuracy and potentially improve tumor margin assessment.
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Affiliation(s)
- Ken Y Foo
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Crawley, Western Australia, Australia
- Department of Electrical, Electronic & Computer Engineering, School of Engineering, The University of Western Australia, Crawley, Western Australia, Australia
| | - Lixin Chin
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Crawley, Western Australia, Australia
- Department of Electrical, Electronic & Computer Engineering, School of Engineering, The University of Western Australia, Crawley, Western Australia, Australia
| | - Renate Zilkens
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Crawley, Western Australia, Australia
- Division of Surgery, Medical School, The University of Western Australia, Crawley, Western Australia, Australia
| | - Devina D Lakhiani
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Crawley, Western Australia, Australia
- Department of Electrical, Electronic & Computer Engineering, School of Engineering, The University of Western Australia, Crawley, Western Australia, Australia
| | - Qi Fang
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Crawley, Western Australia, Australia
- Department of Electrical, Electronic & Computer Engineering, School of Engineering, The University of Western Australia, Crawley, Western Australia, Australia
| | - Rowan Sanderson
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Crawley, Western Australia, Australia
- Department of Electrical, Electronic & Computer Engineering, School of Engineering, The University of Western Australia, Crawley, Western Australia, Australia
| | - Benjamin F Dessauvagie
- PathWest, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
- Division of Pathology and Laboratory Medicine, The University of Western Australia, Crawley, Western Australia, Australia
| | - Bruce Latham
- PathWest, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
- The University of Notre Dame, Fremantle, Western Australia, Australia
| | - Sally McLaren
- PathWest Laboratory Medicine WA, QEII Medical Centre, Nedlands, Western Australia, Australia
| | - Christobel M Saunders
- Division of Surgery, Medical School, The University of Western Australia, Crawley, Western Australia, Australia
- Breast Centre, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
- Breast Clinic, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Brendan F Kennedy
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Crawley, Western Australia, Australia
- Department of Electrical, Electronic & Computer Engineering, School of Engineering, The University of Western Australia, Crawley, Western Australia, Australia
- Australian Research Council Centre for Personalised Therapeutics Technologies, Perth, Western Australia, Australia
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32
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Eaglehouse YL, Georg MW, Jatoi I, Shriver CD, Zhu K. Factors related to re-excision procedures following primary breast-conserving surgery for women with breast cancer in the U.S. Military Health System. J Surg Oncol 2020; 121:200-209. [PMID: 31784990 DOI: 10.1002/jso.25788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 11/17/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND AND OBJECTIVES Re-excision surgery is undertaken to obtain clear margins after breast-conserving surgery (BCS) for localized breast cancer. This study examines patient and tumor characteristics related to re-excision surgery in the universal-access Military Health System (MHS). METHODS Retrospective analysis of patients with pathologically confirmed stage I-III breast cancer between 1998 and 2014 in the Department of Defense Central Cancer Registry and MHS Data Repository-linked databases who received primary BCS. Multivariable stepwise logistic regression methods identified characteristics associated with re-excision surgery (lumpectomy and mastectomy) and conversion to mastectomy, given as adjusted odds ratios (AOR) and 95% confidence intervals (CIs). RESULTS Of 7637 women receiving BCS, 26.3% had a re-excision and 9.9% converted to mastectomy. Tumor location, larger tumor size (≥4 cm), and regional lymph node involvement were associated with a greater likelihood of re-excision and mastectomy conversion. Pathology before BCS (AOR, 0.39; 95% CI, 0.35, 0.44 for re-excision) and neoadjuvant treatment (AOR, 0.50; 95% CI, 0.36, 0.69 for re-excision) were associated with a decreased likelihood of these outcomes. Additionally, age, tumor histology, and military-specific variables were associated with mastectomy conversion. CONCLUSION Comprehensive preoperative workup, including tumor pathology, may better inform surgical decision-making and reduce re-excision rates.
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Affiliation(s)
- Yvonne L Eaglehouse
- Murtha Cancer Center Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Department of Surgery, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Matthew W Georg
- Murtha Cancer Center Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Ismail Jatoi
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Craig D Shriver
- Murtha Cancer Center Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Department of Surgery, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Kangmin Zhu
- Murtha Cancer Center Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland.,Department of Preventive Medicine and Biostatistics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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33
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Landercasper J, Bennie B, Ahmad HF, Linebarger JH. Opportunities to reduce reoperations and to improve inter-facility profiling after initial breast-conserving surgery for cancer. A report from the NCDB. Eur J Surg Oncol 2019; 45:2026-2036. [DOI: 10.1016/j.ejso.2019.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/24/2019] [Accepted: 07/02/2019] [Indexed: 12/21/2022] Open
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34
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Sanchez AM, Franceschini G, D'Archi S, De Lauretis F, Scardina L, Di Giorgio D, Accetta C, Masetti R. Results obtained with level II oncoplastic surgery spanning 20 years of breast cancer treatment: Do we really need further demonstration of reliability? Breast J 2019; 26:125-132. [DOI: 10.1111/tbj.13490] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 04/15/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Alejandro M. Sanchez
- Dipartimento Scienze della Salute della donna e del Bambino, Multidisciplinary Breast Center Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome Italy
| | - Gianluca Franceschini
- Dipartimento Scienze della Salute della donna e del Bambino, Multidisciplinary Breast Center Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome Italy
- Istituto di Semeiotica Chirurgica Università Cattolica del Sacro Cuore Rome Italy
| | - Sabatino D'Archi
- Dipartimento Scienze della Salute della donna e del Bambino, Multidisciplinary Breast Center Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome Italy
| | - Flavia De Lauretis
- Dipartimento Scienze della Salute della donna e del Bambino, Multidisciplinary Breast Center Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome Italy
| | - Lorenzo Scardina
- Dipartimento Scienze della Salute della donna e del Bambino, Multidisciplinary Breast Center Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome Italy
| | - Danilo Di Giorgio
- Dipartimento Scienze della Salute della donna e del Bambino, Multidisciplinary Breast Center Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome Italy
| | - Cristina Accetta
- Dipartimento Scienze della Salute della donna e del Bambino, Multidisciplinary Breast Center Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome Italy
| | - Riccardo Masetti
- Dipartimento Scienze della Salute della donna e del Bambino, Multidisciplinary Breast Center Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome Italy
- Istituto di Semeiotica Chirurgica Università Cattolica del Sacro Cuore Rome Italy
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Abstract
OBJECTIVE The aim of this study was to evaluate the long-term oncologic outcome after oncoplastic surgery (OPS). BACKGROUND OPS combines wide tumor excision with reduction mammoplasty techniques thus extending breast conserving surgery to large tumors that might else be proposed a mastectomy. Little data are available about the oncologic results for breast conserving surgery of these larger tumors. METHODS From January 2004 until March 2016, a total of 350 oncoplastic breast reductions were prospectively entered into a database. Patients were included if their breast reshaping included a reduction mammoplasty with skin excision (Level 2 oncoplastic techniques). RESULTS Histologic subtypes were: invasive ductal carcinoma in 219 cases (62.6%), ductal carcinoma in situ (DCIS) in 88 cases (25.1%), and invasive lobular carcinoma in 43 (12.3%) cases. Seventy-three of the invasive cancers (27.9%) received neoadjuvant chemotherapy. The mean resection weight was 177 grams. The mean pathological tumor size was 26 mm (range 0-180 mm) and varied from 23 mm (4-180 mm) for invasive cancers to 32 mm (0-100 mm) for DCIS. Specimen margins were involved in 12.6% of the cases; 10.5% of invasive ductal, 14.7% of DCIS, and 20.9% of invasive lobular. The overall breast conservation rate was 92% and varied from 87.4% for DCIS to 93.5% for the invasive cancers. Thirty-one patients (8.9%) developed one or more postoperative complications, inducing a delay in postoperative treatments in 4.6% of patients. The median follow up was 55 months. The cumulative 5-year incidences for local, regional, and distant recurrences were 2.2%, 1.1%, and 12.4%, respectively. CONCLUSIONS Oncoplastic breast reductions allow wide resections with free margins and can be used for large cancers as an alternative to mastectomy.
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36
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Landercasper J, Borgert AJ, Fayanju OM, Cody H, Feldman S, Greenberg C, Linebarger J, Pockaj B, Wilke L. Factors Associated with Reoperation in Breast-Conserving Surgery for Cancer: A Prospective Study of American Society of Breast Surgeon Members. Ann Surg Oncol 2019; 26:3321-3336. [PMID: 31342360 PMCID: PMC6733824 DOI: 10.1245/s10434-019-07547-w] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Indexed: 11/18/2022]
Abstract
Background More than 20% of patients undergoing initial breast-conserving surgery (BCS) for cancer require reoperation. To address this concern, the American Society of Breast Surgeons (ASBrS) endorsed 10 processes of care (tools) in 2015 to be considered by surgeons to de-escalate reoperations. In a planned follow-up, we sought to determine which tools were associated with fewer reoperations. Methods A cohort of ASBrS member surgeons prospectively entered data into the ASBrS Mastery® registry on consecutive patients undergoing BCS in 2017. The association between tools and reoperations was estimated via multivariate and hierarchical ranking analyses. Results Seventy-one surgeons reported reoperations in 486 (12.3%) of 3954 cases (mean 12.7% [standard deviation (SD) 7.7%], median 11.5% [range 0–32%]). There was an eightfold difference between surgeons in the 10th and 90th percentile performance groups. Actionable factors associated with fewer reoperations included routine planned cavity side-wall shaves, surgeon use of ultrasound (US), neoadjuvant chemotherapy, intra-operative pathologic margin assessment, and use of a pre-operative diagnostic imaging modality beyond conventional 2D mammography. For patients with invasive cancer, ≥ 24% of those who underwent reexcision did so for reported margins of < 1 or 2 mm, representing noncompliance with the SSO-ASTRO margin guideline. Conclusions Although ASBrS member surgeons had some of the lowest rates of reoperation reported in any registry, significant intersurgeon variability persisted. Further efforts to lower rates are therefore warranted. Opportunities to do so were identified by adopting those processes of care, including improved compliance with the SSO-ASTRO margin guideline, which were associated with fewer reoperations.
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Affiliation(s)
- Jeffrey Landercasper
- Norma J. Vinger Center for Breast Cancer, Gundersen Health System, La Crosse, WI, USA. .,Department of Medical Research, Gundersen Medical Foundation, La Crosse, WI, 54601, USA.
| | - Andrew J Borgert
- Department of Medical Research, Gundersen Medical Foundation, La Crosse, WI, 54601, USA
| | | | - Hiram Cody
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sheldon Feldman
- Montefiore Einstein Center for Cancer Care, Montefiore Medical Center, Bronx, NY, USA
| | - Caprice Greenberg
- University of Wisconsin School of Public Health and Medicine, Madison, WI, USA
| | - Jared Linebarger
- Norma J. Vinger Center for Breast Cancer, Gundersen Health System, La Crosse, WI, USA.,Department of Surgery, Gundersen Health System, La Crosse, WI, USA
| | | | - Lee Wilke
- University of Wisconsin School of Public Health and Medicine, Madison, WI, USA
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37
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Bae MS, Bernard-Davila B, Sung JS, Morris EA. Preoperative breast MRI features associated with positive or close margins in breast-conserving surgery. Eur J Radiol 2019; 117:171-177. [PMID: 31307644 DOI: 10.1016/j.ejrad.2019.06.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 05/31/2019] [Accepted: 06/11/2019] [Indexed: 01/04/2023]
Abstract
PURPOSE To determine preoperative magnetic resonance imaging (MRI) features associated with positive or close margins in patients with breast cancer who underwent breast-conserving surgery (BCS). MATERIALS AND METHODS A retrospective review identified 249 patients with invasive ductal carcinoma (IDC) who underwent preoperative MRI and BCS as a primary procedure between 2008 and 2010. The MR images were reviewed for descriptions of findings with no new interpretations made. Margins were defined as positive (tumor touching the inked specimen margin), close (<2 mm tumor-free margin), or negative (≥2 mm tumor-free margin). Multivariate logistic regression analysis was performed to evaluate imaging and clinical factors predictive of positive or close margins. RESULTS Of the 249 patients, 83 (33.3%) had positive or close margins and 166 (66.7%) had negative margins on the initial BCS specimen. Multivariate analysis showed that multifocal disease (odds ratio, 4.8; 95% CI, 1.9-12.2; p = 0.001), nonmass enhancement lesion (odds ratio, 3.0; 95% CI, 1.5-6.2, p = 0.003), greater background parenchymal enhancement (odds ratio, 2.5; 95% CI, 1.1-5.6; p = 0.023), larger lesion size (odds ratio, 1.3; 95% CI, 1.0-1.7, p = 0.032), and presence of ductal carcinoma in situ on needle biopsy (odds ratio, 2.4; 95% CI, 1.3-4.6; p = 0.008) were independent predictors of positive or close margins. CONCLUSIONS Multifocal disease, nonmass enhancement lesion, or greater background parenchymal enhancement on preoperative breast MRI were significantly associated with positive or close margins. Identifying these MRI features before surgery can be helpful to reduce the reoperation rate in BCS.
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Affiliation(s)
- Min Sun Bae
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY, 10065, United States.
| | - Blanca Bernard-Davila
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY, 10065, United States.
| | - Janice S Sung
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY, 10065, United States.
| | - Elizabeth A Morris
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY, 10065, United States.
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38
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Houvenaeghel G, Lambaudie E, Bannier M, Rua S, Barrou J, Heinemann M, Buttarelli M, Thomassin Piana J, Cohen M. Positive or close margins: reoperation rate and second conservative resection or total mastectomy? Cancer Manag Res 2019; 11:2507-2516. [PMID: 30992681 PMCID: PMC6445211 DOI: 10.2147/cmar.s190852] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Reoperation after breast-conserving surgery (BCS) could be proposed for positive or close margins. Reoperation type, re-excision or mastectomy, depends on several factors in relation to patient's and tumor's characteristics. We have analyzed our breast cancer (BC) database in order to determine second and third attempts for BCS and mastectomy rates, as well as associated factors for type of surgery. Methods All patients with BCS between 1995 and 2017 were included. Patient's characteristics, pathologic results, and treatments were analyzed. Reoperation rate, type of reoperation, second reoperation, and associated factors of reoperation, mastectomy, and third intervention were determined. Three periods were determined: P1-P3. Results We analyzed 10,761 patients: 1,161 with ductal carcinoma in situ (DCIS) and 9,600 with invasive BC. The reoperation rate was 41.4% for DCIS and 28.0% for invasive BC. Using multivariate analysis, we identified tumor size >20 mm as being a risk factor for reoperation, whereas age >50 years, P2-3, and some localization decreased reoperation rates. For invasive BC, age >40 years, triple-negative tumors, neoadjuvant chemotherapy, and noncentral tumors decreased reoperation rates and lobular tumor, multifocal tumors, lymphovascular invasion, DCIS component, and Her2-positive tumors increased reoperation rates. For patients requiring reoperation, re-excision was performed in 48.1% (1,523/3,168) and mastectomy was required after first re-excision in 13.46% (205/1,523). For DCIS, mastectomy rates were higher for grade 2 and tumor ≥20 mm. For invasive BC, mastectomy rates were higher for lobular, multifocal, ≥20 mm, Her2-positive tumors and diffuse positive margins and lower for age >50 years and during the last period. Even if interval time between surgery and adjuvant treatments was higher for patients with reoperation, survival rates were not different between patients with and without reoperation. Conclusion A decrease in reoperation and mastectomy rates had been reported with several associated factors. A third intervention with mastectomy was required in 13.5% of patients. This information should be done in case of reoperation.
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Affiliation(s)
- Gilles Houvenaeghel
- Department of Surgical Oncology, Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, 13009 Marseille, France,
| | - Eric Lambaudie
- Department of Surgical Oncology, Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, 13009 Marseille, France,
| | - Marie Bannier
- Department of Surgical Oncology, Paoli Calmettes Institute, 13009 Marseille, France
| | - Sandrine Rua
- Department of Surgical Oncology, Paoli Calmettes Institute, 13009 Marseille, France
| | - Julien Barrou
- Department of Surgical Oncology, Paoli Calmettes Institute, 13009 Marseille, France
| | - Mellie Heinemann
- Department of Surgical Oncology, Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, 13009 Marseille, France,
| | - Max Buttarelli
- Department of Surgical Oncology, Paoli Calmettes Institute, 13009 Marseille, France
| | - Jeanne Thomassin Piana
- Department of Pathology, Paoli Calmettes Institute and CRCM, CNRS, INSERM, 13009 Marseille, France
| | - Monique Cohen
- Department of Surgical Oncology, Paoli Calmettes Institute, 13009 Marseille, France
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39
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Havel L, Landercasper J. ASO Author Reflections: Rapid Uptake of the SSO ASTRO Margin Guideline and Decreased Reoperations After Lumpectomy: A Success Story. Ann Surg Oncol 2019; 26:1245-1246. [PMID: 30850902 DOI: 10.1245/s10434-019-07289-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Liska Havel
- Gundersen Medical Foundation, La Crosse, WI, USA
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40
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Murphy BL, Glasgow AE, Habermann EB, Hieken TJ. Returns to the operating room after breast surgery at a tertiary care medical center. Am J Surg 2019; 218:388-392. [PMID: 30824169 DOI: 10.1016/j.amjsurg.2019.02.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 02/07/2019] [Accepted: 02/18/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Evaluation of returns to the operating room (RORs) may spur practice modifications to improve patient outcomes and hospital practices. We determined the frequency and indications for RORs after breast operations. METHODS We identified patients ≥18 years who underwent a breast operation at our institution 1/1/14-1/13/17 and assessed ROR within 45-days. RORs were categorized as unplanned/planned, staged/unstaged, or unrelated procedures. Univariate and multivariable analyses compared variables between patients who did and did not have an ROR. RESULTS 2,914 patients underwent a breast operation of whom 117 (4.0%) had 121 RORs. Planned staged procedures accounted for 48 RORs (39.7%), while unplanned complications accounted for 65 (53.7%). On multivariable analysis, ROR was more common among patients undergoing total, skin-sparing, or nipple-sparing mastectomy (versus lumpectomy) all p < 0.03, while immediate breast reconstruction did not increase RORs. CONCLUSIONS RORs following breast operations occurred in 4% of patients, with approximately one-third for a staged oncologic procedure. Implementation of ROR documentation tools should be encouraged, as these data provide benchmarks for clinical practice improvement initiatives to improve the quality of patient care.
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Affiliation(s)
- Brittany L Murphy
- Departments of Surgery, Mayo Clinic, Rochester, MN, USA; The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Surgical Outcomes Program, Mayo Clinic, Rochester, MN, USA
| | - Amy E Glasgow
- The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Surgical Outcomes Program, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth B Habermann
- Departments of Surgery, Mayo Clinic, Rochester, MN, USA; The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Surgical Outcomes Program, Mayo Clinic, Rochester, MN, USA
| | - Tina J Hieken
- Departments of Surgery, Mayo Clinic, Rochester, MN, USA.
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41
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Chagpar AB. Defining Why the Re-excision Rate Dropped. Ann Surg Oncol 2019; 26:1176-1177. [DOI: 10.1245/s10434-019-07248-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Indexed: 11/18/2022]
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42
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Havel L, Naik H, Ramirez L, Morrow M, Landercasper J. Impact of the SSO-ASTRO Margin Guideline on Rates of Re-excision After Lumpectomy for Breast Cancer: A Meta-analysis. Ann Surg Oncol 2019; 26:1238-1244. [DOI: 10.1245/s10434-019-07247-5] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Indexed: 12/12/2022]
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43
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Bruenderman EH, Bhutiani N, Mercer MK, McMasters KM, Sanders MAG, Ajkay NL. Evaluating the relationship between ductal carcinoma in situ, calcifications, and margin status in patients undergoing breast conserving surgery. J Surg Oncol 2019; 119:694-699. [DOI: 10.1002/jso.25388] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 01/14/2019] [Indexed: 11/10/2022]
Affiliation(s)
| | - Neal Bhutiani
- Division of Surgical OncologyDepartment of SurgeryUniversity of LouisvilleLouisville Kentucky
| | - Megan K. Mercer
- Division of Surgical OncologyDepartment of SurgeryUniversity of LouisvilleLouisville Kentucky
| | - Kelly M. McMasters
- Division of Surgical OncologyDepartment of SurgeryUniversity of LouisvilleLouisville Kentucky
| | | | - Nico lás Ajkay
- Division of Surgical OncologyDepartment of SurgeryUniversity of LouisvilleLouisville Kentucky
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44
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Xie W, Chen Y, Wang Y, Wei L, Yin C, Glaser AK, Fauver ME, Seibel EJ, Dintzis SM, Vaughan JC, Reder NP, Liu JTC. Microscopy with ultraviolet surface excitation for wide-area pathology of breast surgical margins. JOURNAL OF BIOMEDICAL OPTICS 2019; 24:1-11. [PMID: 30737911 PMCID: PMC6368047 DOI: 10.1117/1.jbo.24.2.026501] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Accepted: 01/21/2019] [Indexed: 05/06/2023]
Abstract
Intraoperative assessment of breast surgical margins will be of value for reducing the rate of re-excision surgeries for lumpectomy patients. While frozen-section histology is used for intraoperative guidance of certain cancers, it provides limited sampling of the margin surface (typically <1 % of the margin) and is inferior to gold-standard histology, especially for fatty tissues that do not freeze well, such as breast specimens. Microscopy with ultraviolet surface excitation (MUSE) is a nondestructive superficial optical-sectioning technique that has the potential to enable rapid, high-resolution examination of excised margin surfaces. Here, a MUSE system is developed with fully automated sample translation to image fresh tissue surfaces over large areas and at multiple levels of defocus, at a rate of ∼5 min / cm2. Surface extraction is used to improve the comprehensiveness of surface imaging, and 3-D deconvolution is used to improve resolution and contrast. In addition, an improved fluorescent analog of conventional H&E staining is developed to label fresh tissues within ∼5 min for MUSE imaging. We compare the image quality of our MUSE system with both frozen-section and conventional H&E histology, demonstrating the feasibility to provide microscopic visualization of breast margin surfaces at speeds that are relevant for intraoperative use.
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Affiliation(s)
- Weisi Xie
- University of Washington, Department of Mechanical Engineering, Seattle, Washington, United States
| | - Ye Chen
- University of Washington, Department of Mechanical Engineering, Seattle, Washington, United States
| | - Yu Wang
- University of Washington, Department of Mechanical Engineering, Seattle, Washington, United States
| | - Linpeng Wei
- University of Washington, Department of Mechanical Engineering, Seattle, Washington, United States
| | - Chengbo Yin
- University of Washington, Department of Mechanical Engineering, Seattle, Washington, United States
| | - Adam K. Glaser
- University of Washington, Department of Mechanical Engineering, Seattle, Washington, United States
| | - Mark E. Fauver
- University of Washington, Department of Mechanical Engineering, Seattle, Washington, United States
| | - Eric J. Seibel
- University of Washington, Department of Mechanical Engineering, Seattle, Washington, United States
| | - Suzanne M. Dintzis
- University of Washington, School of Medicine, Department of Pathology, Seattle, Washington, United States
| | - Joshua C. Vaughan
- University of Washington, Department of Chemistry, Seattle, Washington, United States
| | - Nicholas P. Reder
- University of Washington, School of Medicine, Department of Pathology, Seattle, Washington, United States
| | - Jonathan T. C. Liu
- University of Washington, Department of Mechanical Engineering, Seattle, Washington, United States
- University of Washington, School of Medicine, Department of Pathology, Seattle, Washington, United States
- Address all correspondence to Jonathan T. C. Liu, E-mail:
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45
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Grant Y, Al-Khudairi R, St John E, Barschkett M, Cunningham D, Al-Mufti R, Hogben K, Thiruchelvam P, Hadjiminas DJ, Darzi A, Carter AW, Leff DR. Patient-level costs in margin re-excision for breast-conserving surgery. Br J Surg 2018; 106:384-394. [PMID: 30566233 DOI: 10.1002/bjs.11050] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/04/2018] [Accepted: 10/06/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND High rates of reoperation following breast-conserving surgery (BCS) for positive margins are associated with costs to healthcare providers. The aim was to assess the quality of evidence on reported re-excision costs and compare the direct patient-level costs between patients undergoing successful BCS versus reoperations after BCS. METHODS The study used data from women who had BCS with or without reoperation at a single institution between April 2015 and March 2016. A systematic review of health economic analysis in BCS was conducted and scored using the Quality of Health Economic Studies (QHES) instrument. Financial data were retrieved using the Patient-Level Information and Costing Systems (PLICS) for patients. Exchange rates used were: US $1 = £0·75, £1 = €1·14 and US $1 = €0·85. RESULTS The median QHES score was 47 (i.q.r. 32·5-79). Only two of nine studies scored in the upper QHES quartile (score at least 75). Costs of initial lumpectomy and reoperation were in the range US $1234-11786 and $655-9136 respectively. Over a 12-month interval, 153 patients had definitive BCS and 59 patients underwent reoperation. The median cost of reoperations after BCS (59 patients) was £4511 (range 1752-18 019), representing an additional £2136 per patient compared with BCS without reoperation (P < 0·001). CONCLUSION The systematic review demonstrated variation in methodological approach to cost estimates and a paucity of high-quality cost estimate studies for reoperations. Extrapolating local PLICS data to a national level suggests that getting BCS right first time could result in substantial savings.
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Affiliation(s)
- Y Grant
- Department of BioSurgery and Surgical Technology, Imperial College London, London, UK
| | - R Al-Khudairi
- Department of BioSurgery and Surgical Technology, Imperial College London, London, UK
| | - E St John
- Department of BioSurgery and Surgical Technology, Imperial College London, London, UK
| | - M Barschkett
- Department of BioSurgery and Surgical Technology, Imperial College London, London, UK
| | - D Cunningham
- Breast Unit, Imperial College Healthcare NHS Trust, London, UK
| | - R Al-Mufti
- Breast Unit, Imperial College Healthcare NHS Trust, London, UK
| | - K Hogben
- Breast Unit, Imperial College Healthcare NHS Trust, London, UK
| | - P Thiruchelvam
- Breast Unit, Imperial College Healthcare NHS Trust, London, UK
| | - D J Hadjiminas
- Breast Unit, Imperial College Healthcare NHS Trust, London, UK
| | - A Darzi
- Department of BioSurgery and Surgical Technology, Imperial College London, London, UK
| | - A W Carter
- Department of BioSurgery and Surgical Technology, Imperial College London, London, UK
| | - D R Leff
- Department of BioSurgery and Surgical Technology, Imperial College London, London, UK.,Breast Unit, Imperial College Healthcare NHS Trust, London, UK
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McEvoy MP, Landercasper J, Naik HR, Feldman S. Update of the American Society of Breast Surgeons Toolbox to address the lumpectomy reoperation epidemic. Gland Surg 2018; 7:536-553. [PMID: 30687627 DOI: 10.21037/gs.2018.11.03] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In 2015, the American Society of Breast Surgeons (ASBrS) convened a multidisciplinary consensus conference, the Collaborative Attempt to Lower Lumpectomy Reoperation Rates (CALLER). The CALLER conference endorsed a "toolbox" of multiple processes of care for which there was evidence that they were associated with fewer reoperations. We present an update of the toolbox taking into consideration the latest advances in decreasing re excision rates. In this review, we performed a comprehensive review of the literature from 2015-2018 using search terms for each tool. The original ten tools were updated with the latest evidence from the literature and our strength of recommendation. We added an additional section looking at new tools and techniques that may provide more accurate intraoperative assessment of margins. The updates on the CALLER Toolbox for lumpectomy will help guide surgeons to various resources to aid in the removal of breast cancer, while being aware of cosmesis and decreasing re excision rates.
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Affiliation(s)
- Maureen P McEvoy
- Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, USA
| | - Jeffrey Landercasper
- Gundersen Health System, Norma J. Vinger Center for Breast Cancer, La Crosse, WI, USA
| | - Himani R Naik
- Gundersen Health System, Norma J. Vinger Center for Breast Cancer, La Crosse, WI, USA
| | - Sheldon Feldman
- Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, USA
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47
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Chen JY, Huang YJ, Zhang LL, Yang CQ, Wang K. Comparison of Oncoplastic Breast-Conserving Surgery and Breast-Conserving Surgery Alone: A Meta-Analysis. J Breast Cancer 2018; 21:321-329. [PMID: 30275861 PMCID: PMC6158154 DOI: 10.4048/jbc.2018.21.e36] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 07/11/2018] [Indexed: 12/28/2022] Open
Abstract
Purpose The use of oncoplastic reconstruction for breast-conserving surgery (BCS) extends benefits beyond merely minimizing poor cosmetic results. However, the feasibility and oncological safety of oncoplastic surgery (OPS) are controversial. Methods This meta-analysis aimed to compare the short-term and long-term oncological outcomes of BCS alone and BCS plus OPS. Relevant studies published before July 2017 in the Embase, the Cochrane Library, PubMed, and Web of Science databases were screened and collected. The meta-analysis was performed using STATA software (Stata Corp.). Results A total of 3,789 patients from 11 studies were included, with 2,691 patients in the BCS-alone group and 1,098 patients in the BCS plus OPS group. The demographics were similar between both groups, and no significant difference was observed in pathological T and N stages between the two groups. Re-excision was less common (relative risk [RR], 0.66; p=0.009) and the positive-margin rate was lower, but not significantly (RR, 0.83; p=0.191), in the BCS plus OPS group than in the BCS-alone group. The local and distal recurrence rates were similar in both groups. Both disease-free survival (hazard ratio [HR], 1.19; 95% confidence interval [CI], 0.96-1.49; p=0.112) and overall survival (HR, 1.14; 95% CI, 0.76-1.69; p=0.527) did not differ between the two groups. Conclusion A combination of BCS and OPS is preferred over BCS alone for decreasing re-excisions and provides similar long-term survival as BCS alone in patients with breast cancer.
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Affiliation(s)
- Jun-Ying Chen
- Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Yi-Jie Huang
- Department of General Surgery, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Liu-Lu Zhang
- Department of Breast Cancer, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Ci-Qiu Yang
- Department of Breast Cancer, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Kun Wang
- Department of Breast Cancer, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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48
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Shipp DW, Rakha EA, Koloydenko AA, Macmillan RD, Ellis IO, Notingher I. Intra-operative spectroscopic assessment of surgical margins during breast conserving surgery. Breast Cancer Res 2018; 20:69. [PMID: 29986750 PMCID: PMC6038277 DOI: 10.1186/s13058-018-1002-2] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 06/04/2018] [Indexed: 11/17/2022] Open
Abstract
Background In over 20% of breast conserving operations, postoperative pathological assessment of the excised tissue reveals positive margins, requiring additional surgery. Current techniques for intra-operative assessment of tumor margins are insufficient in accuracy or resolution to reliably detect small tumors. There is a distinct need for a fast technique to accurately identify tumors smaller than 1 mm2 in large tissue surfaces within 30 min. Methods Multi-modal spectral histopathology (MSH), a multimodal imaging technique combining tissue auto-fluorescence and Raman spectroscopy was used to detect microscopic residual tumor at the surface of the excised breast tissue. New algorithms were developed to optimally utilize auto-fluorescence images to guide Raman measurements and achieve the required detection accuracy over large tissue surfaces (up to 4 × 6.5 cm2). Algorithms were trained on 91 breast tissue samples from 65 patients. Results Independent tests on 121 samples from 107 patients - including 51 fresh, whole excision specimens - detected breast carcinoma on the tissue surface with 95% sensitivity and 82% specificity. One surface of each uncut excision specimen was measured in 12–24 min. The combination of high spatial-resolution auto-fluorescence with specific diagnosis by Raman spectroscopy allows reliable detection even for invasive carcinoma or ductal carcinoma in situ smaller than 1 mm2. Conclusions This study provides evidence that this multimodal approach could provide an objective tool for intra-operative assessment of breast conserving surgery margins, reducing the risk for unnecessary second operations. Electronic supplementary material The online version of this article (10.1186/s13058-018-1002-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Dustin W Shipp
- School of Physics and Astronomy, University of Nottingham, Nottingham, NG7 2RD, UK
| | - Emad A Rakha
- Division of Oncology, School of Medicine, University of Nottingham, Nottingham, NG5 1PB, UK
| | - Alexey A Koloydenko
- Mathematics Department, Royal Holloway, University of London, Egham, TW20 0EX, UK
| | - R Douglas Macmillan
- Nottingham Breast Institute, Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB, UK
| | - Ian O Ellis
- Division of Oncology, School of Medicine, University of Nottingham, Nottingham, NG5 1PB, UK
| | - Ioan Notingher
- School of Physics and Astronomy, University of Nottingham, Nottingham, NG7 2RD, UK.
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Landercasper J. Why Do Reoperation Rates Vary So Much After Lumpectomy for Breast Cancer? Examining the Reoperation Puzzle at the Massachusetts General Hospital. Ann Surg Oncol 2018; 25:2506-2508. [DOI: 10.1245/s10434-018-6609-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Indexed: 11/18/2022]
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50
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Cassar Q, Al-Ibadi A, Mavarani L, Hillger P, Grzyb J, MacGrogan G, Zimmer T, Pfeiffer UR, Guillet JP, Mounaix P. Pilot study of freshly excised breast tissue response in the 300-600 GHz range. BIOMEDICAL OPTICS EXPRESS 2018; 9:2930-2942. [PMID: 29984076 PMCID: PMC6033580 DOI: 10.1364/boe.9.002930] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 01/09/2018] [Accepted: 04/24/2018] [Indexed: 05/25/2023]
Abstract
The failure to accurately define tumor margins during breast conserving surgery (BCS) results in a 20% re-excision rate. The present paper reports the investigation to evaluate the potential of terahertz imaging for breast tissue recognition within the under-explored 300 - 600 GHz range. Such a frequency window matches new BiCMOS technology capabilities and thus opens up the opportunity for near-field terahertz imaging using these devices. To assess the efficacy of this frequency band, data from 16 freshly excised breast tissue samples were collected and analyzed directly after excision. Complex refractive indices have been extracted over the as-mentioned frequency band, and amplitude frequency images show some contrast between tissue types. Principal component analysis (PCA) has also been applied to the data in an attempt to automate tissue classification. Our observations suggest that the dielectric response could potentially provide contrast for breast tissue recognition within the 300 - 600 GHz range. These results open the way for silicon-based terahertz subwavelength near field imager design, efficient up to 600 GHz to address ex vivo life-science applications.
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Affiliation(s)
- Quentin Cassar
- Integration: from Material to Systems Laboratory, UMR CNRS 5218, University of Bordeaux, 33400 Talence, France
| | - Amel Al-Ibadi
- Integration: from Material to Systems Laboratory, UMR CNRS 5218, University of Bordeaux, 33400 Talence, France
| | - Laven Mavarani
- Institute for High-Frequency and Communication Technology, University of Wuppertal, 42119 Wuppertal, Germany
| | - Philipp Hillger
- Institute for High-Frequency and Communication Technology, University of Wuppertal, 42119 Wuppertal, Germany
| | - Janusz Grzyb
- Institute for High-Frequency and Communication Technology, University of Wuppertal, 42119 Wuppertal, Germany
| | - Gaëtan MacGrogan
- Department of Pathology, Bergonié Institute, 33076 Bordeaux, France
| | - Thomas Zimmer
- Integration: from Material to Systems Laboratory, UMR CNRS 5218, University of Bordeaux, 33400 Talence, France
| | - Ullrich R. Pfeiffer
- Institute for High-Frequency and Communication Technology, University of Wuppertal, 42119 Wuppertal, Germany
| | - Jean-Paul Guillet
- Integration: from Material to Systems Laboratory, UMR CNRS 5218, University of Bordeaux, 33400 Talence, France
| | - Patrick Mounaix
- Integration: from Material to Systems Laboratory, UMR CNRS 5218, University of Bordeaux, 33400 Talence, France
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