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Zaborowski AM, Wong SM. Neoadjuvant systemic therapy for breast cancer. Br J Surg 2023; 110:765-772. [PMID: 37104057 PMCID: PMC10683941 DOI: 10.1093/bjs/znad103] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/02/2023] [Indexed: 04/28/2023]
Affiliation(s)
| | - Stephanie M Wong
- Department of Surgery and Oncology, McGill University Medical School, Montreal, Quebec, Canada
- Segal Cancer Centre, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada
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2
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Comparison of excised breast volume, re-excision rate and margin positivity in breast-conserving surgery in breast cancer patients using and not using neoadjuvant chemotherapy. JOURNAL OF SURGERY AND MEDICINE 2022. [DOI: 10.28982/josam.1049330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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3
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Walcott-Sapp S, Srour MK, Lee M, Luu M, Amersi F, Giuliano A, Chung A. Can Radiologic Tumor Size Following Neoadjuvant Therapy Reliably Guide Tissue Resection in Breast Conserving Surgery in Patients with Invasive Breast Cancer? Am Surg 2021; 86:1248-1253. [PMID: 33284669 DOI: 10.1177/0003134820964209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Optimum tissue resection volume for patients with invasive breast cancer undergoing breast conserving surgery following neoadjuvant therapy (NAT) is not known. We compared positive margin and in-breast tumor recurrence (IBTR) between 2 groups that were created based on radiologic tumor size (RTS (cm3)) at diagnosis, RTS post-NAT, and volume of tissue resected (VTL): Pre-NAT group, patients with VTL closer to RTS at diagnosis, and post-NAT group, patients with VTL closer to post-NAT RTS. 82 patients with 84 breast cancers treated with NAT between 2007 and 2017 who had pre- and post-NAT imaging were identified from a prospectively maintained database. RTS at diagnosis, RTS post-NAT, and VTL were determined. Clinical and treatment characteristics, IBTR, and disease-free survival (DFS) were compared between pre-NAT (n = 51) and post-NAT (n = 33) groups. Compared to post-NAT patients, pre-NAT patients had smaller RTS at presentation (9.2 vs. 33.5 cm3, P < .001) and post-NAT (1.2 vs. 8.2 cm3, P = .024). At median follow-up of 4 years, there were no differences between groups in pathologic tumor size, positive margin rate, adjuvant therapy, IBTR, or DFS. Resection volumes that matched RTS on post-NAT imaging were not associated with increased positive margins or IBTR. It may be appropriate to use post-NAT imaging to guide lumpectomy volume.
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Affiliation(s)
| | | | - Minna Lee
- UCLA Jonsson Cancer Center, Los Angeles, CA, USA
| | - Michael Luu
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Farin Amersi
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Alice Chung
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
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4
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Woeste MR, Bhutiani N, Donaldson M, McMasters KM, Ajkay N. Evaluating the effect of neoadjuvant chemotherapy on surgical outcomes after breast conserving surgery. J Surg Oncol 2020; 123:439-445. [PMID: 33259649 DOI: 10.1002/jso.26301] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/27/2020] [Accepted: 11/05/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND Neoadjuvant chemotherapy (NAC) increases breast-conserving surgery (BCS) rates with comparable locoregional control and survival outcomes to adjuvant therapy. More women are receiving NAC and achieving pathologic complete responses (pCR). This study sought to evaluate the effect of NAC on surgical outcomes after the adoption of a "no-ink-on-tumor" margin policy in patients undergoing primary BCS (PBSC). METHODS An IRB approved database was queried for women undergoing BCS for invasive breast cancer after March 2014. We compared patients who underwent NAC followed by BCS versus PBCS. Demographic, tumor, treatment, and outcome variables were compared using both univariate and multivariable analysis. RESULTS A total of 162 patients were evaluated. NAC patients had significantly lower re-excision rates (0% NAC vs. 9% PBCS, p = .03), margin positivity (0% NAC vs. 5% PBCS, p = .01), and greater patient satisfaction with breast cosmesis (97 NAC vs. 77 PBCS, p = .01). On multivariable analysis, NAC was not an independent predictor of lower final resection volume, total complications, or greater satisfaction with breasts when controlling for age and T category at diagnosis. CONCLUSION NAC followed by BCS may offer less margin positivity, lower re-excision rates, and greater patient satisfaction when compared to a contemporary PBCS cohort in the "no-ink-on-tumor" era.
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Affiliation(s)
- Matthew R Woeste
- Division of Surgical Oncology, Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Neal Bhutiani
- Division of Surgical Oncology, Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Marilyn Donaldson
- Division of Surgical Oncology, Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Kelly M McMasters
- Division of Surgical Oncology, Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Nicolás Ajkay
- Division of Surgical Oncology, Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
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5
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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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Davoine E, Dion L, Nyangoh Timoh K, Beraud E, Tas P, Tavenard A, Laviolle B, Perrin C, Foucher F, Levêque J, Lavoué V. Predictive factors associated with involved margins in breast cancer treated with neoadjuvant chemotherapy followed by breast-conserving therapy. J Gynecol Obstet Hum Reprod 2019; 48:467-472. [DOI: 10.1016/j.jogoh.2019.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 05/03/2019] [Accepted: 06/09/2019] [Indexed: 10/26/2022]
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7
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Murugappan K, Saboo A, Kuo L, Ung O. Paradigm shift in the local treatment of breast cancer: mastectomy to breast conservation surgery. Gland Surg 2018; 7:506-519. [PMID: 30687624 PMCID: PMC6323252 DOI: 10.21037/gs.2018.09.01] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 09/03/2018] [Indexed: 01/16/2023]
Abstract
There have been fundamental changes in the approach to breast cancer management over the last century but the primary objective of achieving oncological safety remains unchanged. This evolution is highlighted with a summary of the key evidences in support of the oncological safety of breast conserving surgery (BCS) in early breast cancer (EBC) management. We will also discuss the increasingly pivotal role that neoadjuvant chemotherapy (NACT) may play, in the local treatment of EBC and locally advanced breast cancer (LABC) and the long-term surgical and oncological outcomes.
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Affiliation(s)
- Kowsi Murugappan
- Royal Brisbane Breast Surgery Unit, Department of General Surgery, RBWH, Brisbane, Australia
- University of Queensland, Brisbane, Australia
| | - Apoorva Saboo
- Royal Brisbane Breast Surgery Unit, Department of General Surgery, RBWH, Brisbane, Australia
| | - Lu Kuo
- University of Queensland, Brisbane, Australia
| | - Owen Ung
- Royal Brisbane Breast Surgery Unit, Department of General Surgery, RBWH, Brisbane, Australia
- University of Queensland, Brisbane, Australia
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8
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Brouwer de Koning SG, Vrancken Peeters MJTFD, Jóźwiak K, Bhairosing PA, Ruers TJM. Tumor Resection Margin Definitions in Breast-Conserving Surgery: Systematic Review and Meta-analysis of the Current Literature. Clin Breast Cancer 2018; 18:e595-e600. [PMID: 29731404 DOI: 10.1016/j.clbc.2018.04.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 03/28/2018] [Accepted: 04/04/2018] [Indexed: 12/11/2022]
Abstract
Worldwide, various guidelines recommend what constitutes an adequate margin of excision for invasive breast cancer or for ductal carcinoma-in-situ (DCIS). We evaluated the use of different tumor resection margin guidelines and investigated their impact on positive margin rates (PMR) and reoperation rates (RR). Thirteen guidelines reporting on the extent of a positive margin were reviewed along with 31 studies, published between 2011 and 2016, reporting on a well-defined PMR. Studies were categorized according to the margin definition. Pooled PMR and RR were determined with random-effect models. For invasive breast cancer, most guidelines recommend a positive margin of tumor on ink. However, definitions of reported positive margins in the clinic vary from more than focally positive to the presence of tumor cells within 3 to 5 mm from the resection surface. Within the studies analyzed (59,979 patients), pooled PMRs for invasive breast cancer ranged from 9% to 36% and pooled RRs from 77% to 99%. For DCIS, guidelines vary between no DCIS on the resection surface to DCIS cells found within a distance of 2 mm from the resection edge. Pooled PMRs for DCIS varied from 4% to 23% (840 patients). Given the differences in tumor margin definition between countries worldwide, quality control data expressed as PMR or RR should be interpreted with caution. Furthermore, the overall definition for positive resection margins for both invasive disease and DCIS seems to have become more liberal.
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Affiliation(s)
| | | | - Katarzyna Jóźwiak
- Department of Epidemiology and Biostatistics, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Patrick A Bhairosing
- Scientific Information Service, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Theo J M Ruers
- Department of Surgery, The Netherlands Cancer Institute, Amsterdam, The Netherlands; MIRA Institute, University of Twente, Enschede, The Netherlands
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Breast-conserving surgery following neoadjuvant therapy-a systematic review on surgical outcomes. Breast Cancer Res Treat 2017; 168:1-12. [PMID: 29214416 PMCID: PMC5847047 DOI: 10.1007/s10549-017-4598-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 08/07/2017] [Indexed: 01/14/2023]
Abstract
Purpose Neoadjuvant chemotherapy (NACT) is increasingly used in breast cancer treatment. One of the main goals of NACT is to reduce the extent of local surgery of the breast and axilla. The aim of this study was to determine surgical outcomes for patients receiving breast-conserving therapy (BCT) after NACT, including margin status plus secondary surgeries, excision volumes, and cosmetic outcomes. Methods A systematic review was performed in accordance with PRISMA principles. Pubmed, MEDLINE, Embase, and the Cochrane Library were searched for studies investigating the results of BCT following NACT. The main study outcomes were margin status, additional local therapies, excision volumes, and cosmetic outcomes. Non-comparative studies on NACT were also included. Exclusion criteria were studies with less than 25 patients, and studies excluding secondary mastectomy patients. Findings Of the 1219 studies screened, 26 studies were deemed eligible for analysis, including data from 5379 patients treated with NACT and 10,110 patients treated without NACT. Included studies showed wide ranges of tumor-involved margins (2–39.8%), secondary surgeries (0–45.4%), and excision volumes (43.2–268 cm3) or specimen weight (26.4–233 g) after NACT. Most studies were retrospective, with a high heterogeneity and a high risk of bias. Cosmetic outcomes after NACT were reported in two single-center cohort studies. Both studies showed acceptable cosmetic outcomes. Interpretation There is currently insufficient evidence to suggest that NACT improves surgical outcomes of BCT. It is imperative that clinical trials include patient outcome measures in order to allow monitoring and meaningful comparison of treatment outcomes in breast cancer.
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Barry PA, Schiavon G. Primary Systemic Treatment in the Management of Operable Breast Cancer: Best Surgical Approach for Diagnosis, Biological Evaluation, and Research. J Natl Cancer Inst Monogr 2016; 2015:4-8. [PMID: 26063876 DOI: 10.1093/jncimonographs/lgv008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Despite the ever-changing breast surgeon's technical role, the surgeon forms an indispensible link between imaging, diagnostics, pathology, and the medical oncologist. Biomarkers of prognosis, prediction of response, and resistance to treatments, including imaging, tissue and circulating markers apply to the primary diagnostic and treatment settings as well as scenarios which include disease recurrence, both in the early and advanced settings. Whether it is via the diagnostic clinic referred by the primary care physician or via a breast screening service, primary early breast cancer is referred for initial treatment and/or diagnosis and currently remains the domain of the surgical oncologist. The surgeon is privileged by this unique "window of opportunity" to consider the biological aspects of the diagnosis and guide the patient appropriately toward initial therapy, only one of which is primary surgery. Options of neoadjuvant endocrine, cytotoxic, or targeted therapy as either standard of care or else in the clinical trial context should be considered to optimize treatment in all patients.
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Affiliation(s)
- Peter A Barry
- The Royal Marsden NHS Foundation Trust, Breast Unit, London, UK (PAB, GS); The Institute of Cancer Research, London, UK (PAB, GS); Translational Science, Oncology iMed, AstraZeneca, Cambridge SciencePark, Cambridge, UK (GS).
| | - Gaia Schiavon
- The Royal Marsden NHS Foundation Trust, Breast Unit, London, UK (PAB, GS); The Institute of Cancer Research, London, UK (PAB, GS); Translational Science, Oncology iMed, AstraZeneca, Cambridge SciencePark, Cambridge, UK (GS)
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11
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Factors associated with surgical management in an underinsured, safety net population. Surgery 2016; 159:580-90. [DOI: 10.1016/j.surg.2015.08.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 08/11/2015] [Accepted: 08/15/2015] [Indexed: 01/11/2023]
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Factors which affect the use of lumpectomy and mastectomy in an underinsured, safety net hospital population. Am J Surg 2014; 209:985-91. [PMID: 25457245 DOI: 10.1016/j.amjsurg.2014.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 06/25/2014] [Accepted: 07/21/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND This study was performed to evaluate variables that affect the use of mastectomy and lumpectomy in an underinsured population. METHODS A retrospective review of all patients who underwent breast cancer operations from July 2001 to February 2011 at a safety net hospital was performed. Univariate and multivariate analyses were performed to identify variables, which were associated with the type of operation. RESULTS Of the 412 patients, 81% of the patients were underinsured or uninsured. Most patients (58%) presented with clinical stage 2A/B disease. Mastectomy was performed in 37% of patients and lumpectomy in 63%. In multivariate analysis, clinical tumor size (P = .035) and pathologic stage (P = .003) remained associated with mastectomy, while use of preoperative chemotherapy (P = .004) and type of surgeon (P = .001) was associated with lumpectomy. CONCLUSIONS Most patients underwent lumpectomy despite later stage at presentation. Preoperative chemotherapy was associated with increased likelihood of lumpectomy.
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Olsen-Deeter L, Hsu CH, Nodora JN, Bouton ME, Nalagan J, Martinez ME, Komenaka IK. Factors which affect use of breast conservation and mastectomy in an underinsured Hispanic population. Surg Oncol 2014; 23:186-91. [PMID: 25443563 DOI: 10.1016/j.suronc.2014.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 08/19/2014] [Accepted: 09/11/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Despite no difference in overall survival between breast conservation and mastectomy, significant variation exists between institutions and within populations. Less data exists about racial and ethnic minority populations. The current study was performed to evaluate variables that affect use of breast conservation and mastectomy in an underinsured Hispanic population. METHODS A retrospective review was performed of all patients who self-identified as of Hispanic ethnicity and underwent breast cancer operations from July 2001 to February 2011 at a safety net hospital. Sociodemographic, clinical, and treatment variables were evaluated. All patients with documented contraindications to breast conservation were excluded. Univariate analysis and multivariate analysis were performed to identify variables which were associated with type of operation. RESULTS The average age of the 219 patients included was 50 years. Most of the patients (93%) were insured with Medicaid or uninsured and 59% presented with clinical stage 2A/B cancers. Mastectomy was performed in 33% of patients and 67% had breast conservation. In adjusted multivariate analysis higher pathologic stage (p=0.01) and English speakers (p=0.03) were associated with mastectomy. By contrast, higher BMI (p=0.03) and use of preoperative chemotherapy (p=0.01) were associated with breast conservation. CONCLUSIONS In this underinsured Hispanic population, patients with higher pathologic stage and English speaking patients were more likely to undergo mastectomy. Patients who underwent preoperative chemotherapy and who had higher BMI were more likely to undergo breast conservation.
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Affiliation(s)
| | - Chiu-Hsieh Hsu
- Arizona Cancer Center, University of Arizona, Tucson, AZ, USA; Mel and Enid Zuckerman Arizona College of Public Health, University of Arizona, Tucson, AZ, USA
| | - Jesse N Nodora
- Moores University of California San Diego Cancer Center, San Diego, CA, USA
| | | | | | | | - Ian K Komenaka
- Maricopa Medical Center, Phoenix, AZ, USA; Arizona Cancer Center, University of Arizona, Tucson, AZ, USA.
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14
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Predictors of margin status after breast-conserving operations in an underscreened population. Langenbecks Arch Surg 2012. [DOI: 10.1007/s00423-012-1023-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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