The efficacy of specimen radiography in evaluating the surgical margins of impalpable breast carcinoma

Diagnostic accuracy of intraoperative methods for margin assessment in breast cancer surgery: A systematic review & meta-analysis

PURPOSE

There are a wide variety of intraoperative techniques available in breast surgery to achieve low rates for positive margins of excision. The objective of this systematic review was to determine the pooled diagnostic accuracy of intraoperative breast margin assessment techniques that have been evaluated in clinical practice.

METHODS

This study was performed in accordance with PRISMA guidelines. A systematic search of the literature was conducted to identify studies assessing the diagnostic accuracy of intraoperative margin assessment techniques. Only clinical studies with raw diagnostic accuracy data as compared with final permanent section histopathology were included in the meta-analysis. A bivariate model for diagnostic meta-analysis was used to determine overall pooled sensitivity and specificity.

RESULTS

Sixty-one studies were eligible for inclusion in this systematic review and meta-analysis. Cytology demonstrated the best diagnostic accuracy, with pooled sensitivity of 0.92 (95 % CI 0.77-0.98) and a pooled specificity of 0.95 (95 % CI 0.90-0.97). The findings also indicate good diagnostic accuracy for optical spectroscopy, with a pooled sensitivity of 0.86 (95 % CI 0.76-0.93) and a pooled specificity of 0.92 (95 % CI 0.82-0.97).

CONCLUSION

Pooled data indicate that optical spectroscopy, cytology and frozen section have the greatest diagnostic accuracy of currently available intraoperative margin assessment techniques. However, long turnaround time for results and their resource intensive nature has prevented widespread adoption of these methods. The aim of emerging technologies is to compete with the diagnostic accuracy of these established techniques, while improving speed and usability.

Localisation accuracy with iodine-125 seed versus wire guidance for breast cancer surgery

INTRODUCTION

Impalpable breast lesions generally require image-guided localisation for breast-conserving surgery. A standard technique is to place a hook wire (HW) within the lesion. Radioguided occult lesion localisation using iodine seeds (ROLLIS) involves inserting a 4.5 mm iodine-125 seed (seed) into the lesion. We hypothesised that a seed could be more precisely positioned in relation to the lesion than a HW and that this may be associated with a lower re-excision rate.

METHODS

Retrospective review of consecutive participant data from three ROLLIS RCT (ACTRN12613000655741) sites. Participants underwent preoperative lesion localisation (PLL) with seed or HW between September 2013 and December 2017. Lesion and procedural characteristics were recorded. Distances between (1) any part of the seed or thickened segment of the HW ('TSHW') and the lesion/clip ('distance to device' DTD) and (2) centre of the TSHW/seed and centre of the lesion/clip (device centre to target centre 'DCTC') were measured on immediate postinsertion mammograms. Pathological margin involvement and re-excision rates were compared.

RESULTS

A total of 390 lesions (190 ROLLIS and 200 HWL) were analysed. Lesion characteristics and guidance modality used were similar between groups. Ultrasound-guided DTD and DCTC for seed were smaller than for HW (77.1% and 60.6%, respectively, P-value < 0.001). Stereotactic-guided DCTC for seeds was 41.6% smaller than for HW (P-value = 0.001). No statistically significant difference in the re-excision rates was found.

CONCLUSION

Iodine-125 seeds can be more precisely positioned for preoperative lesion localisation than HW, however, no statistically significant difference in re-excision rates was detected.

Specimen mammography for intraoperative margin assessment in breast conserving surgery: a meta-analysis

In breast conserving surgery (BCS), specimen mammography is one of the most widely used intraoperative methods of assessing margin status. We performed a meta-analysis to evaluate the diagnostic accuracy of specimen mammography. Literature databases including PubMed, Cochrane Library, Web of Science, and EMBASE were searched prior to Jun 2022. A total of 1967 patients were included from 20 studies. A pooled analysis, heterogeneity testing, threshold effect testing, publication bias analysis, and subgroup analyses were performed from extracted data. The pooled weighted values were a sensitivity of 0.55 (95% confidence interval [CI], 0.47-0.63), a specificity of 0.85 (95% CI, 0.78-0.90), a diagnostic odds ratio of 7 (95% CI, 4-12), and a pooled positive likelihood ratio of 3.7 (95% CI 2.6-5.5). The area under the receiver operator characteristic curve was 0.75 (95% CI 0.71-0.78). In the subgroup analysis, the pooled specificity in the positive margin defined as tumor at margin subgroup was lower than the other positive margin definition subgroup (0.82 [95% CI: 0.71, 0.92] vs. 0.87 [95% CI: 0.80, 0.94], p = 0.01). Our findings indicated that specimen mammography was an accurate intraoperative imaging technique for margin assessment in BCS.

Diagnostic accuracy of radiography, digital breast tomosynthesis, micro-CT and ultrasound for margin assessment during breast surgery: A systematic review and meta-analysis

RATIONALE AND OBJECTIVES

Achieving adequate resection margins in breast conserving surgery is challenging and often demands more than one surgical procedure. We evaluated pooled diagnostic sensitivity, and specificity of radiological methods for intraoperative margin assessment and their impact on repeat surgery rate.

MATERIALS AND METHODS

We included studies using radiography, digital breast tomosynthesis (DBT), micro-CT, and ultrasound for intraoperative margin assessment with the histological assessment as the reference method. A systematic search was performed in PubMed, Embase, Cochrane Library, Scopus, and Web of Science. Two investigators screened the studies for eligibility criteria and extracted data of the included studies independently. The quality assessment on diagnostic accuracy studies (QUADAS)-2 tool was used. A bivariate random effect model was used to obtained pooled sensitivity and specificity of the index tests in the meta-analysis.

RESULTS

The systematic search resulted in screening of 798 unique records. Twenty-two articles with 29 radiological imaging methods were selected for meta-analysis. Pooled sensitivity and specificity and area under the curve were calculated for each of the 4 subgroups in the meta-analysis respectively: Radiography; 52%, 77%, 60%, DBT; 67%, 76%, 76%, micro-CT; 68%, 69%, 72%, and ultrasound; 72%, 78%, 80%. The repeat surgery rate was poorly reported in the included studies.

CONCLUSION

Ultrasound showed the highest and radiography the lowest diagnostic performance for intraoperative margin assessment. However, the heterogeneity between studies was high and the subgroups small. The radiological methods for margin assessment need further improvement to provide reliable guidance in the clinical workflow and to prevent repeat surgeries.

Rapid assessment of breast tumor margins using deep ultraviolet fluorescence scanning microscopy

SIGNIFICANCE

Re-excision rates for women with invasive breast cancer undergoing breast conserving surgery (or lumpectomy) have decreased in the past decade but remain substantial. This is mainly due to the inability to assess the entire surface of an excised lumpectomy specimen efficiently and accurately during surgery.

AIM

The goal of this study was to develop a deep-ultraviolet scanning fluorescence microscope (DUV-FSM) that can be used to accurately and rapidly detect cancer cells on the surface of excised breast tissue.

APPROACH

A DUV-FSM was used to image the surfaces of 47 (31 malignant and 16 normal/benign) fresh breast tissue samples stained in propidium iodide and eosin Y solutions. A set of fluorescence images were obtained from each sample using low magnification (4  ×  ) and fully automated scanning. The images were stitched to form a color image. Three nonmedical evaluators were trained to interpret and assess the fluorescence images. Nuclear-cytoplasm ratio (N/C) was calculated and used for tissue classification.

RESULTS

DUV-FSM images a breast sample with subcellular resolution at a speed of 1.0  min  /  cm2. Fluorescence images show excellent visual contrast in color, tissue texture, cell density, and shape between invasive carcinomas and their normal counterparts. Visual interpretation of fluorescence images by nonmedical evaluators was able to distinguish invasive carcinoma from normal samples with high sensitivity (97.62%) and specificity (92.86%). Using N/C alone was able to differentiate patch-level invasive carcinoma from normal breast tissues with reasonable sensitivity (81.5%) and specificity (78.5%).

CONCLUSIONS

DUV-FSM achieved a good balance between imaging speed and spatial resolution with excellent contrast, which allows either visual or quantitative detection of invasive cancer cells on the surfaces of a breast surgical specimen.

Is specimen radiography still necessary in patients with non-palpable breast cancer undergoing breast-conserving surgery using radioactive I-125 seed localization?

AIM

To evaluate the diagnostic performance for margin assessment of specimen radiography (SR) in breast conserving surgery (BCS) using radioactive I¹²⁵-seed localization (RSL).

METHODS

The clinical, radiographic and histopathological data of women who underwent BCS after pre-operative RSL with intraoperative SR during nine consecutive years were analyzed. The histological margin and radiographic margin outcomes on SR were compared and results of intraoperative re-excisions were investigated.

RESULTS

A consecutive series of 448 women with invasive carcinoma (n = 211), ductal carcinoma in situ (DCIS) (n = 79) and a combination of DCIS and invasive carcinoma (n = 158) were included. The median minimal margins for the radiological masses and microcalcifications measured on SR were 14 mm and 11 mm, respectively. Based on a radiological cut-off SR margin value of 1 mm, the overall sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were 21.0%, 95.0%, 26.0%, and 94.0%, respectively. The area under the receiver-operating curve was 0.73. Intraoperative re-excisions based on SR were performed in 31 (6.9%) patients; histopathological examination of the additional excised tissue revealed DCIS or invasive carcinoma in 6 (19.4%) patients. Hence, SR was beneficial for 6/448 patients (1.3%), and unnecessary intraoperative re-excisions were performed in 20/448 patients (4.5%). The number need to treat is 75; this implies that per 75-SR one resection with involved margins is prevented.

CONCLUSION

SR has a moderate diagnostic performance for margin involvement using RSL. A more accurate intraoperative margin assessment tool is warranted.

Lumpectomy Specimen Radiography: Does Orientation or 3-Dimensional Tomosynthesis Improve Margin Assessment?

Purpose

Our purpose was twofold. First, we sought to determine whether 2 orthogonal oriented views of excised breast cancer specimens could improve surgical margin assessment compared to a single unoriented view. Second, we sought to determine whether 3D tomosynthesis could improve surgical margin assessment compared to 2D mammography alone.

Materials and Methods

Forty-one consecutive specimens were prospectively imaged using 4 protocols: single view unoriented 2D image acquired on a specimen unit (1VSU), 2 orthogonal oriented 2D images acquired on the specimen unit (2VSU), 2 orthogonal oriented 2D images acquired on a mammogram unit (2V2DMU), and 2 orthogonal oriented 3D images acquired on the mammogram unit (2V3DMU). Three breast imagers randomly assessed surgical margin of the 41 specimens with each protocol. Surgical margin per histopathology was considered the gold standard.

Results

The average area under the curve (AUC) was 0.60 for 1VSU, 0.66 for 2VSU, 0.68 for 2V2DMU, and 0.60 for 2V3DMU. Comparing AUCs for 2VSU vs 1VSU by reader showed improved diagnostic accuracy using 2VSU; however, this difference was only statistically significant for reader 3 (0.73 vs 0.63, P = .0455). Comparing AUCs for 2V3DMU vs 2V2DMU by reader showed mixed results, with reader 1 demonstrating increased accuracy (0.72 vs 0.68, P = .5984), while readers 2 and 3 demonstrated decreased accuracy (0.50 vs 0.62, P = .1089 and 0.58 vs 0.75, P = .0269).

Conclusions

2VSU showed improved accuracy in surgical margin prediction compared to 1VSU, although this was not statistically significant for all readers. 3D tomosynthesis did not improve surgical margin assessment.

Digital Breast Tomosynthesis as a Tool in Confirming Negative Surgical Margins in Non-palpable Breast Lesions

Breast cancer is one of the leading killers among women the world over. Widespread mammographic screening programs have led to almost 20% of breast cancers being detected when they are radiologically visible but clinically impalpable. For the localization of these cancers before surgical excision, the Kopan hook wire is the standard technique, but the extent of margins excised still needs to be determined. In this study, we have evaluated the accuracy of specimen mammogram (SM) with digital breast tomosynthesis (DBT) for margin assessment by comparing it to the excised margins as measured in final histopathology. This is a prospective observational study of patients with radiologically suspicious impalpable breast lesions. The patients underwent ultrasound-guided hook wire placement followed by excision of the lesion, subjected to digital tomosynthesis mammogram, and margins were revised on table when indicated. These findings were correlated with final histopathological margin. Our study included 30 patients and out of the 6 lesions, which showed positive margins on specimen mammography, 4 were histologically confirmed to have tumour at the surgical margin and 2 were confirmed to be tumour free. All DBT-positive margins were re-excised at the time of primary surgery. Individual comparison of the margins revealed a good agreement and high level of correlation between DBT and histopathology margins. None of the cases required a second surgery for margin revision. It can be concluded that specimen mammogram with DBT can be used as a reliable tool for intraoperative surgical margin assessment in non-palpable breast lesions to reduce rate of margin revision as well as reduce the volume of breast excised without compromising the oncological safety of the procedure.

Feasibility of Micro-Computed Tomography Imaging for Direct Assessment of Surgical Resection Margins During Breast-Conserving Surgery

BACKGROUND

To analyze the feasibility and accuracy of micro-computed tomography (micro-CT) for surgical margin assessment in breast excision specimen.

MATERIALS AND METHODS

Two data sets of 30 micro-CT scans were retrospectively evaluated for positive resection margins by four observers in two phases, using pathology as a gold standard. Results of phase 1 were evaluated to define micro-CT evaluation guidelines for phase 2. Interobserver agreement was also assessed (kappa). In addition, a prospective study was conducted in which 40 micro-CT scans were directly acquired, reconstructed, and evaluated for positive resection margins by one observer. A suspect positive resection margin on micro-CT was annotated onto the specimen with ink, enabling local validation by pathology. Main outcome measures were accuracy, sensitivity, specificity, and positive predictive value (PPV).

RESULTS

Average accuracy, sensitivity, specificity, and PPV for the four observers were 63%, 38%, 70%, and 22%, respectively, in phase 1 and 72%, 40%, 78%, and 26%, respectively, in phase 2. The interobserver agreement was fair [kappa (range), 0.31 (0.12-0.80) in phase 1 and 0.23 (0-0.43) in phase 2]. In the prospective study 70% of the surgical resection margins were correctly evaluated. Ten specimens were annotated for positive resection margins, which correlated with three positive and three close (<1 mm) margins on pathology. Sensitivity, specificity, and PPV were 38%, 78%, and 30%, respectively.

CONCLUSIONS

Micro-CT imaging of breast excision specimen has moderate accuracy and considerable interobserver variation for analysis of surgical resection margins. Especially sensitivity and PPV need to be improved before micro-CT-based margin assessment can be introduced in clinical practice.

Rapid pathology of lumpectomy margins with open-top light-sheet (OTLS) microscopy

Open-top light-sheet microscopy is a technique that can potentially enable rapid ex vivo inspection of large tissue surfaces and volumes. Here, we have optimized an open-top light-sheet (OTLS) microscope and image-processing workflow for the comprehensive examination of surgical margin surfaces, and have also developed a novel fluorescent analog of H&E staining that is robust for staining fresh unfixed tissues. Our tissue-staining method can be achieved within 2.5 minutes followed by OTLS microscopy of lumpectomy surfaces at a rate of up to 1.5 cm2/minute. An image atlas is presented to show that OTLS image quality surpasses that of intraoperative frozen sectioning and can approximate that of gold-standard H&E histology of formalin-fixed paraffin-embedded (FFPE) tissues. Qualitative evidence indicates that these intraoperative methods do not interfere with downstream post-operative H&E histology and immunohistochemistry. These results should facilitate the translation of OTLS microscopy for intraoperative guidance of lumpectomy and other surgical oncology procedures.

Modeling the binding and diffusion of receptor-targeted nanoparticles topically applied on fresh tissue specimens

Nanoparticle (NP) contrast agents targeted to cancer biomarkers are increasingly being engineered for the early detection of cancer, guidance of therapy, and monitoring of response. There have been recent efforts to topically apply biomarker-targeted NPs on tissue surfaces to image the expression of cell-surface receptors over large surface areas as a means of evaluating tumor margins to guide wide local excision surgeries. However, diffusion and nonspecific binding of the NPs present challenges for relating NP retention on the tissue surface with the expression of cancer cell receptors. Paired-agent methods that employ a secondary 'control' NP to account for these nonspecific effects can improve cancer detection. Yet these paired-agent methods introduce multidimensional complexity (with tissue staining, rinsing, imaging, and data analysis protocols all being subject to alteration), and could be greatly simplified with accurate, predictive in silico models of NP binding and diffusion. Here, we outline and validate such a model to predict the diffusion, as well as specific and nonspecific binding, of targeted and control NPs topically applied on tissue surfaces. In order to inform the model, in vitro experiments were performed to determine relevant NP diffusion and binding rate constants in tissues. The predictive capacity of the model was validated by comparing simulated distributions of various sizes of NPs in comparison with experimental results. The regression of predicted and experimentally measured concentration-depth profiles yielded  <15% error (compared to ~70% error obtained using a previous model of NP diffusion and binding).

Optical palpation for the visualization of tumor in human breast tissue

Accurate and effective removal of tumor in one operation is an important goal of breast-conserving surgery. However, it is not always achieved. Surgeons often utilize manual palpation to assess the surgical margin and/or the breast cavity. Manual palpation, however, is subjective and has relatively low resolution. Here, we investigate a tactile imaging technique, optical palpation, for the visualization of tumor. Optical palpation generates maps of the stress at the surface of tissue under static preload compression. Stress is evaluated by measuring the deformation of a contacting thin compliant layer with known mechanical properties using optical coherence tomography. In this study, optical palpation is performed on 34 freshly excised human breast specimens. Wide field-of-view (up to ~46 × 46 mm) stress images, optical palpograms, are presented from four representative specimens, demonstrating the capability of optical palpation to visualize tumor. Median stress reported for adipose tissue, 4 kPa, and benign dense tissue, 8 kPa, is significantly lower than for invasive tumor, 60 kPa. In addition, we demonstrate that optical palpation provides contrast consistent with a related optical technique, quantitative micro-elastography. This study demonstrates that optical palpation holds promise for visualization of tumor in breast-conserving surgery.

Factors influencing reoperation following breast-conserving surgery

BACKGROUND

Reoperation rates after breast-conserving surgery are highly variable and the best techniques for optimizing margin clearance are being evaluated. The aim was to identify the reoperation rate at our centre and identify influential factors, including a change in guidelines on margin recommendations and the introduction of in-theatre specimen X-ray.

METHODS

A retrospective review of medical records was undertaken to identify 562 patients who underwent breast conservation at The Royal Melbourne Hospital and Royal Women's Hospital between 2013 and 2015. All cases that underwent subsequent re-excision or total mastectomy were captured and factors influencing margin excision recorded.

RESULTS

Reoperation was undertaken in 19.5% of patients (110; 86 re-excisions and 24 total mastectomies). There was a reduction in reoperation rate from 25% to 17% (P = 0.01) with adoption of the margin guidelines in 2014, but no significant reduction with the introduction of in-theatre specimen X-ray in 2015 (21% versus 16%, P = 0.14). On multivariate analysis, factors that significantly influenced reoperation rates were the presence of multifocality on mammogram (odds ratio (OR): 5.3, 95% confidence interval (CI): 1.6-16.7, P < 0.01); lesion size on mammogram (OR: 2.2 per 10 mm, 95% CI: 1.4-3.6, P < 0.01); smaller excision specimen weight (OR: 0.5 per 25 g of resection, 95% CI: 0.3-0.8, P < 0.01); and pure ductal carcinoma in situ on final pathology (OR: 5.9, 95% CI: 1.9-16.7, P < 0.01).

CONCLUSION

Optimizing reoperation rates following breast-conserving surgery remains a surgical challenge, particularly in patients with in situ or multifocal disease. Adoption of international margin guidelines reduced reoperation rates at our centre; however, introduction of intraoperative specimen X-ray had no influence.

High Residual Tumor Rate for Early Breast Cancer Patients Receiving Vacuum-assisted Breast Biopsy

Purpose: The objective of study is aiming to investigate the residual tumor rate after Vacuum-assisted Breast Biopsy (VABB) for early breast cancer excision and the efficacy of mammogram and ultrasound in detecting residual tumor.

Methods: Patients who underwent VABB and were confirmed with breast cancer in Sun Yat-sen University Cancer Center from 2010 to 2015 were reviewed retrospectively. The residual tumor rate determined by histological examination was calculated, and then was compared with the results estimated by mammogram and ultrasound which were performed post VABB but before subsequent surgery. Univariate and multivariate analysis (logistic regression) were carried out to identify the independent risk factors associated with residual tumor.

Results: In total, 126 eligible patients with early breast cancer were recruited for this study, of whom 79 (62.7%) had residual tumor and 47 (37.3 %) underwent complete excision. The residual tumor rates for lesions < 10mm, lesions 10 to 20 mm and lesions >20mm in size were 55.0%, 68.9% and 53.1%, respectively. The complete excision rates estimated by mammogram and ultrasound were 76.5% and 73.9%, with a negative predictive value of only 46.2% and 50.6%, respectively. In the multivariate logistic regression analysis, no specific factors were found associated with risk of residual tumor (all P > 0.05).

Conclusions: There was a high residual tumor rate after VABB in early breast cancer. Both mammogram and ultrasound could not effectively detect the residual tumor after VABB.

Wide-field optical coherence micro-elastography for intraoperative assessment of human breast cancer margins

Incomplete excision of malignant tissue is a major issue in breast-conserving surgery, with typically 20 - 30% of cases requiring a second surgical procedure arising from postoperative detection of an involved margin. We report advances in the development of a new intraoperative tool, optical coherence micro-elastography, for the assessment of tumor margins on the micro-scale. We demonstrate an important step by conducting whole specimen imaging in intraoperative time frames with a wide-field scanning system acquiring mosaicked elastograms with overall dimensions of ~50 × 50 mm, large enough to image an entire face of most lumpectomy specimens. This capability is enabled by a wide-aperture annular actuator with an internal diameter of 65 mm. We demonstrate feasibility by presenting elastograms recorded from freshly excised human breast tissue, including from a mastectomy, lumpectomies and a cavity shaving.

Comparison of intra-operative specimen mammography to standard specimen mammography for excision of non-palpable breast lesions: a randomized trial

Standard specimen mammography (SSM) is performed in the radiology department after wire-localized excision of non-palpable breast lesions to confirm the presence of the target and evaluate margins. Alternatively, intra-operative specimen mammography (ISM) allows surgeons to view images in the operating room (OR). We conducted a randomized study comparing ISM and SSM. Women undergoing wire-localized excision for breast malignancy or imaging abnormality were randomized to SSM or ISM. For SSM, the specimen was transported to the radiology department for imaging and interpretation. For ISM, the specimen was imaged in the OR for interpretation by the surgeon and sent for SSM. Interpretation time was from specimen leaving OR until radiologist interpretation for SSM and from placement in ISM device until surgeon interpretation for ISM. Procedure and interpretation times were compared. Concordance between ISM and SSM for target and margins was evaluated. 72 patients were randomized, 36 ISM and 36 SSM. Median procedure times were similar, 48.5 (17-138) min for ISM, and 54 (17-40) min for SSM (p = 0.72), likely since specimens in both groups traveled to radiology for SSM. Median interpretation time was significantly shorter with ISM, 1 (0.5-2.0) and 9 (4-16) min for ISM and SSM, respectively (p < 0.0001). Among specimens with ISM and SSM, concordance was 100 % (35/35) for target and 93 % (14/15) for margins. In this randomized trial, use of ISM compared with SSM significantly reduced interpretation times, while accurately identifying the target. This could result in decreased operative costs from shorter OR times with use of ISM.

What to look for on a breast specimen radiograph: lessons learnt

Two women underwent stereotactic sampling of mammographically detected lesions with insertion of breast biopsy markers. Localisation of the malignant lesions was performed using iodine 125 seeds, with bracketing of the edges of the larger lesion. The seeds/lesions were located and excised using a γ probe. Liga clips attached to peripheral sutures at the edges of the specimen enabled radiographic orientation. Surgeon and radiologist found the specimen radiographs difficult to interpret. In one case the surgeon thought the lesion had been removed, mistaking the iodine seed for the biopsy marker. The radiologist noted absence of the biopsy marker and marginal calcifications but was concerned the seed was absent. Widening the window level allowed seed identification, revealing a characteristic rectangular radiolucent area in what had been interpreted as a Liga clip. Correct interpretation of the findings helped guide lesion removal, intraoperative margin re-excision and confirmed (125)I seed retrieval.

Clinical evaluation of a mobile digital specimen radiography system for intraoperative specimen verification

OBJECTIVE

Use of mobile digital specimen radiography systems expedites intraoperative verification of excised breast specimens. The purpose of this study was to evaluate the performance of a such a system for verifying targets.

MATERIALS AND METHODS

A retrospective review included 100 consecutive pairs of breast specimen radiographs. Specimens were imaged in the operating room with a mobile digital specimen radiography system and then with a conventional digital mammography system in the radiology department. Two expert reviewers independently scored each image for image quality on a 3-point scale and confidence in target visualization on a 5-point scale. A target was considered confidently verified only if both reviewers declared the target to be confidently detected.

RESULTS

The 100 specimens contained a total of 174 targets, including 85 clips (49%), 53 calcifications (30%), 35 masses (20%), and one architectural distortion (1%). Although a significantly higher percentage of mobile digital specimen radiographs were considered poor quality by at least one reviewer (25%) compared with conventional digital mammograms (1%), 169 targets (97%), were confidently verified with mobile specimen radiography; 172 targets (98%) were verified with conventional digital mammography. Three faint masses were not confidently verified with mobile specimen radiography, and conventional digital mammography was needed for confirmation. One faint mass and one architectural distortion were not confidently verified with either method.

CONCLUSION

Mobile digital specimen radiography allows high diagnostic confidence for verification of target excision in breast specimens across target types, despite lower image quality. Substituting this modality for conventional digital mammography can eliminate delays associated with specimen transport, potentially decreasing surgical duration and increasing operating room throughput.

Breast cancer: Actual methods of treatment and future trends

The recent ten to twenty years have seen a substantial progress in the diagnosis and treatment of breast cancer. A rapid development of various curative options has led to the improvement of treatment outcomes, while paying more and more attention to the aspects of quality of life and cosmetic effect. In our publication, we wish to outline certain trends in the development of modern treatment of breast cancer. Among topics discussed are new forms of molecular diagnostics, new approach to the idea of sentinel node biopsy, as well as new techniques for delivery of medical procedures, the increasing use of nomograms, progress in the techniques of breast conservative treatment, modern approach to occult breast lesions, the increasing use of neoadjuvant treatment and intraoperative radiotherapy.

Future directions for monitoring treatment responses in breast cancer

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

Micro-computed tomography (Micro-CT): a novel approach for intraoperative breast cancer specimen imaging

Intraoperative radiographic examination of breast specimens is commonly performed to confirm excision of image-detected breast lesions, but it is not reliable for assessing margin status. A more accurate method of intraoperative breast specimen imaging is needed. Micro-CT provides quantitative imaging parameters, image rotation, and virtual "slicing" of intact breast specimens. We explored the use of micro-CT for assessment of a variety of clinical breast specimens. Specimens were evaluated with a table top micro-CT scanner, Skyscan 1173 (Skyscan, Belgium), with a 40-130 kV, 8 W X-ray source. Skyscan software for 3D image analysis (Dataviewer and CTVox) was employed to review 3D graphics of specimens. Scanning for 7 min and another 7 min for image reconstruction provided the desired resolution for breast specimens. Breast lumpectomy specimens, shaved cavity margins, mastectomy specimens, and axillary lymph nodes were imaged by micro-CT. The micro-CT images could be rotated in all directions and cross sections of internal portions of specimens could be visualized from any angle. This provided information about spatial orientation of masses and calcifications relative to margins in intact lumpectomy specimens. Micro-CT is a potentially useful tool for assessment of breast cancer specimens, allowing real-time analysis of tumor location in breast lumpectomy specimens or shaved cavity margins. Micro-CT may also be useful for assessing sentinel lymph nodes and mastectomy specimens.

Rapid Stereomicroscopic Imaging of HER2 Overexpression in Ex Vivo Breast Tissue Using Topically Applied Silica-Based Gold Nanoshells

Tumor margin detection for patients undergoing breast conservation surgery primarily occurs postoperatively. Previously, we demonstrated that gold nanoshells rapidly enhance contrast of HER2 overexpression in ex vivo tissue sections. Our ultimate objective, however, is to discern HER2 overexpressing tissue from normal tissue in whole, nonsectioned, specimens to facilitate rapid diagnoses. Here, we use targeted nanoshells to quickly and effectively visualize HER2 receptor expression in intact ex vivo human breast tissue specimens. Punch biopsies of human breast tissue were analyzed after a brief 5-minute incubation with and without HER2-targeted silica-gold nanoshells using two-photon microscopy and stereomicroscopy. Labeling was subsequently verified using reflectance confocal microscopy, darkfield hyperspectral imaging, and immunohistochemistry to confirm levels of HER2 expression. Our results suggest that anti-HER2 nanoshells used in tandem with a near-infrared reflectance confocal microscope and a standard stereomicroscope may potentially be used to discern HER2-overexpressing cancerous tissue from normal tissue in near real time and offer a rapid supplement to current diagnostic techniques.

Evaluation of lumpectomy surgical specimen radiographs in subclinical, in situ and invasive breast cancer, and factors predicting positive margins

PURPOSE

To determine the diagnostic performance of radiological evaluation of the margins of surgical specimens from lumpectomies for subclinical malignant breast lesions.

MATERIALS AND METHODS

Retrospective study in two French hospitals including all patients who had a non-palpable in situ (ISDC) or invasive (IDC) ductal carcinoma treated by lumpectomy after radiological localisation. For the analysis, the lesions were divided into two groups depending on the majority component in the definitive histological examination: ISDC or IDC. The radiological margin considered was 10mm.

RESULTS

For the 178 lumpectomies studied, the sensitivity of the radiographs of the surgical specimen was 33.3% for ISDC and 50% for IDC. The surgical revision rate was 27.41% for ISDC and 12.64% for IDC. The significant predictive factors for positive margins were the radiological size of the lesions (>10mm) for ISDC (P=0.02) and radiologically positive margins for IDC (P=0.01). Correlation was found between the histological and radiological sizes of the lesion for IDC, but not for ISDC.

CONCLUSION

Radiological examination of surgical specimens does not provide a satisfactory evaluation of the histological margins, in particular for ISDC, even with a radiological threshold of 10mm.

Toward MR-guided high intensity focused ultrasound for presurgical localization: focused ultrasound lesions in cadaveric breast tissue

PURPOSE

To investigate magnetic resonance image-guided high intensity focused ultrasound (MR-HIFU) as a surgical guide for nonpalpable breast tumors by assessing the palpability of MR-HIFU-created lesions in ex vivo cadaveric breast tissue.

MATERIALS AND METHODS

MR-HIFU ablations spaced 5 mm apart were made in 18 locations using the ExAblate2000 system. Ablations formed a square perimeter in mixed adipose and fibroglandular tissue. Ablation was monitored using T1-weighted fast spin echo images. MR-acoustic radiation force impulse (MR-ARFI) was used to remotely palpate each ablation location, measuring tissue displacement before and after thermal sonications. Displacement profiles centered at each ablation spot were plotted for comparison. The cadaveric breast was manually palpated to assess stiffness of ablated lesions and dissected for gross examination. This study was repeated on three cadaveric breasts.

RESULTS

MR-ARFI showed a collective postablation reduction in peak displacement of 54.8% ([4.41 ± 1.48] μm pre, [1.99 ± 0.82] μm post), and shear wave velocity increase of 65.5% ([10.69 ± 1.60] mm pre, [16.33 ± 3.10] mm post), suggesting tissue became stiffer after the ablation. Manual palpation and dissection of the breast showed increased palpability, a darkening of ablation perimeter, and individual ablations were visible in mixed adipose/fibroglandular tissue.

CONCLUSION

The results of this preliminary study show MR-HIFU has the ability to create palpable lesions in ex vivo cadaveric breast tissue, and may potentially be used to preoperatively localize nonpalpable breast tumors.

[Specimen radiography assessment of surgical margins status in subclinical breast carcinoma: a diagnostic study]

OBJECTIVE

This study aimed to determine the accuracy of specimen radiography in evaluating the surgical margins of impalpable breast carcinoma.

DESIGN AND SETTING

Retrospective study from June 2009 to June 2010 in Orleans Hospital Center.

PATIENTS AND METHODS

The study involved patients with impalpable in situ breast carcinoma diagnosed by mammography. Only patients with larger in situ carcinoma than invasive carcinoma were included. Patients underwent a breast conserving surgery after preoperative localization of the lesion.

PRIMARY ENDPOINT

Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the specimen radiography are determined by correlation between radiologic and histologic margins.

RESULTS AND DISCUSSION

The following results were obtained from 46 patients: 36 DCIS cases (78%), six DCIS with IDC cases (13%), two LCIS cases (4%) and two biopsy suggested DCIS (4%). A radiologic margin of 2mm (by analogy with the histological margins) results in a NPV of 73%. NPV, sensibility and specificity were respectively 79, 60 and 74% for a radiologic margin of 5mm. The measure or inter-rater reliability found a moderate agreement (kappa: 0.62). The systematic review on this topic found only eight articles (small samples and only two prospective studies). We could not make any recommendations from the literature review on a threshold to define excision margin status.

CONCLUSION

The specimen radiography is a useful tool to assess margins of impalpable breast carcinoma. However, further studies are necessary as this point to determine a threshold for those radiologic margins.

Accuracy of frozen section analysis versus specimen radiography during breast-conserving surgery for nonpalpable lesions

BACKGROUND

Whereas specimen radiography (SR) is an established strategy for intraoperative resection margin analysis during breast-conserving surgery for nonpalpable lesions, the use of frozen section analysis (FSA) is still a matter of debate.

METHODS

A retrospective review was conducted of 115 consecutive operations in which the two objectives sought were the excision of nonpalpable malignant lesions and breast conservation. Breast surgery was performed in the Gynecology and the Surgery Departments at the Basel University Hospital Breast Center. Whereas one department preferably uses SR for intraoperative margin assessments of lesions involving ductal carcinoma in situ (DCIS) or atypical ductal hyperplasia, the other uses FSA to increase the rate of complete removal of these lesions with a single procedure. The respective accuracy and therapeutic impact of these two techniques are compared here.

RESULTS

Intraoperative resection margin assessments were performed with FSA in 80 and SR in 35 of a total of 115 operations performed on 111 patients with pTis, pT1, or pT2 nonpalpable breast cancer. FSA diagnostic accuracy, sensitivity, and specificity were 83.8%, 80.0%, and 87.5%, respectively, compared to 60%, 60%, and 60%, respectively, for SR. FSA tended to have a stronger therapeutic impact than SR in terms of the number of patients in whom initially positive margins were rendered margin-negative thanks to intraoperative analysis and immediate reexcision or mastectomy (27.5% vs. 14.3%; p = 0.124). More importantly, significantly fewer secondary reexcisions were performed in the FSA series than in the SR series (12.5% vs. 37.1%; p = 0.002). Finally, the intraoperative detection of invasive cancer with FSA led to a significantly lower number of secondary procedures for axillary lymph node staging (5% vs. 25.7%; p = 0.001).

CONCLUSIONS

The present results suggest that FSA may be more accurate than SR for analyzing intraoperative resection margins during breast-conserving surgery for nonpalpable lesions.

Intraoperative Digital Specimen Mammography: Rapid, Accurate Results Expedite Surgery

INTRODUCTION

Specimen mammography during image guided breast surgery is a daily occurrence. The process of specimen travel, imaging and reporting may take 20-30 minutes. An intraoperative method to obtain digital specimen mammograms may expedite the process. We compared intraoperative digital specimen mammography (IDSM) as well as standard specimen mammography (SSM) on 121 consecutive image guided lumpectomies.

METHODS

Each lumpectomy specimen had IDSM obtained followed by travel to radiology for SSM. Surgical decisions were based on all imaging obtained. Data included 1) the ability of each imaging method to identify the target lesion, 2) degree of concordance of surgical interpretation of IDSM compared to radiologist interpretation of SSM, 3) the time required from lumpectomy to surgical review of images from each method, and 4) potential operative time savings.

RESULTS

Intraoperative digital specimen mammography (IDSM) was equally as accurate as standard x-ray film specimen mammography. There was no significant difference between 1) the frequency of identification of the target lesion by surgeon or radiologist, 2) lack of identification of any lesion, or 3) frequency of involved margins using imaging criteria. However, there was a marked difference in 1) the time needed to obtain images ready to read, 2) the ability to re-excise tissue promptly, and 3) the overall operating room time with an average decrease of 19 minutes.

CONCLUSIONS

Intraoperative digital specimen mammography (IDSM) was equally accurate as SSM obtained in this study. Use of this new technology allows surgeons to quickly view specimen images which translate into shorter more efficient operations.

Breast specimen radiography: can it predict margin status of excised breast carcinoma?

RATIONALE AND OBJECTIVES

This study examined the value of intraoperative specimen radiography (SR) in determining margin status of excised breast lesions. Of interest was the concordance between the radiologic and histopathologic interpretation of margins. We investigated the influence of in situ disease and of one versus two radiologic views on this concordance.

MATERIALS AND METHODS

Our study consisted of 112 women who underwent breast conservation therapy (BCT) during 2002. Margins were examined with one- or two-view SR. Margins were histologically positive if malignant cells resided < or = 1 mm from the specimen edge. The McNemar's test was used to determine concordance between SR and histopathology (HP). Because surgeons excised extra tissue in cases of positive radiologic margins, we believe that a change in margin status occurred in which true positives became false positives. Accordingly, we analyzed our data with multiple iterations in which, one by one, false positives were considered true positives.

RESULTS

Concordance between SR and HP reached statistical significance after 5/17 false positives were considered true positives. Data excluding DCIS reached significance after 6 of 6 false positives were considered true positives. One- and two-view SR reached significance when 2 of 8 and 7 of 9 false positives, respectively, were considered true positives.

CONCLUSION

In conclusion, our study suggests that SR can aid in margin assessment for patients undergoing BCT. We did not find that concordance between SR and HP is higher in cases of purely invasive disease. Concordance was higher in one-view SR in comparison to two-view. A larger sample size should be analyzed before recommending against using two views.

Specimen radiography as predictor of resection margin status in non-palpable breast lesions

AIM

This study aimed to evaluate the role of specimen radiography in predicting margin status for non-palpable breast malignancies.

METHODS

We retrospectively reviewed the clinical and pathological data together with specimen radiographs of 164 women with ductal carcinoma in situ, who were referred to our centre between January 1997 and December 2000. In all cases microcalcifications were discovered on mammography. Lesions were localized preoperatively using a guide-wire. Specimen radiography findings and clinicopathological data were correlated with pathological findings.

RESULTS

Findings comprised 122 pure ductal carcinomas in situ (74%) and 42 mixed carcinomas, both infiltrating and in situ (26%). On the specimen radiographs, the lesions were close (<1mm) to one edge of the lumpectomy in 34 (21%) cases. Histologically, there were 103 positive resection margins (<1mm, 63%) and only 61 negative margins (> or =1mm, 37%). On univariate analysis, factors associated with positive resection margins were found to be distance from microcalcifications to edge of lesion on specimen radiographs, and radiological multifocality. On multivariate analysis (logistic regression), a radiological margin <5mm and multifocality were the only risk factors for close histological margins. Radiological margins were not associated with surgical findings.

CONCLUSION

Our results demonstrate that there is a correlation between specimen radiographs and histological results. The clinical relevance of this should be evaluated in a prospective study.

Radiological review of specimen radiographs after breast localisation biopsy is not always necessary

INTRODUCTION

The use of specimen radiographs to confirm the presence of the radiological abnormality in a breast specimen after localisation biopsy is standard practice. This study aims to show that a trained surgeon may assess breast specimen radiographs with similar efficacy as a radiologist.

METHODS

This retrospective study assessed all patients who had localisation breast surgery using wire or ultrasound (US) techniques between January 2002 and March 2003. Histopathological records and mammographic details were recorded from the hospital notes. A consultant radiologist and surgeon reviewed the specimen radiographs, identifying mammographic abnormalities and assessing margins.

RESULTS

Localisation surgery was performed on 101 patients with US used to localize 68. The median specimen weight was 64g. A malignant diagnosis was made in 86 patients. In 23, the histological resection margins were considered to be close or involved by tumour and re-excision was performed in eight patients. Sixty-one specimen radiographs were reviewed. The radiologist identified every mammographic abnormality, and the surgeon identified the lesion in 58. The positive predictive value of specimen radiographs to identify histologically involved margins was 75 and 74% by the radiologist and the surgeon, respectively. Where good radiograph margins were reported in 40 and 35 patients by the radiologist and surgeon, respectively, 11 and 7 had histologically involved margins.

CONCLUSIONS

This study shows that a suitably trained or experienced surgeon can assess specimen radiographs effectively without the need for intraoperative radiological input although complete histological resection is not guaranteed despite specimen radiographs demonstrating clear margins.

Sonography of Postexcision Specimens of Nonpalpable Breast Lesions: Value, Limitations, and Description of a Method

OBJECTIVE

The objective of our study was to retrospectively review our experience regarding the value of sonography in identifying a nonpalpable mass within a surgically excised specimen and in assessing the surgical margins in cases of malignancy.

MATERIALS AND METHODS

One hundred four lumpectomies were performed in 99 consecutive patients with 131 nonpalpable breast lesions after sonographically guided needle localization. All 104 surgical specimens were scanned on sonography, and 86 specimen radiographs were obtained. Visualization of the lesion on sonography was compared with specimen radiographs and histologic findings. Sonographic margin status was classified as negative (shortest distance between tumor and specimen margin, > 0.2 cm) or positive (shortest distance between tumor and specimen margin, 0.2 cm) and was compared with pathology results.

RESULTS

Specimen sonography showed 95.4% (125/131) of the excised abnormalities; nonfatty background and a lesion size of greater than 0.5 cm contributed significantly to the success of specimen sonography. Four of six lesions missed on sonography were identified on specimen radiography. Among 81 malignant specimens, sonography identified 38 specimens with positive margins and 43 with negative margins. Pathologic examination revealed eight false-positive and 10 false-negative results (21% false-positive rate and 23.2% false-negative rate).

CONCLUSION

Specimen sonography is an effective procedure for identifying the presence of the lesion within the specimen; however, it is of limited value in cases of small hypoechoic lesions against a fatty background. Assessment of margins is limited by both false-positive and false-negative results.

A needle-localised open-breast biopsy for nonpalpable breast lesions should not be performed for diagnosis

BACKGROUND

The achievement of tumour-free margins on excision of nonpalpable breast lesions that have aroused only an intermediate or low level of suspicion before surgery and do turn out to be malignant is a challenge for the surgeon. The purpose of this study was to determine factors that influence the probability of obtaining tumour-free margins after needle-localised excision of a nonpalpable breast carcinoma.

METHOD

During a 10-year period all needle-localised breast biopsies (NLBB) carried out in the Department of Surgery were retrospectively analysed. Possible influential factors considered included: age of the patient, year of NLBB, appearance of the lesion on imaging, preoperative diagnostic index, method of localisation, surgeon's level of experience, specimen size and radiology of the specimen, and all these were analysed in a multivariate logistic regression analysis.

RESULTS

In all, 400 needle-localised breast biopsies had been performed. Excision with tumour-free margins was more often achieved, and the final intervention less often took the form of a mastectomy, when the lesion was classified preoperatively as malignant (P = 0.02).

CONCLUSION

The outcome of treatment of a needle-localised breast cancer excision is better when the breast lesion is known to be malignant before surgery.

Analysis of the use of specimen mammography in breast conservation therapy

BACKGROUND

Obtaining tumor-negative margins when performing breast-conserving surgery is the standard of care to prevent local recurrence. We believe two-view specimen mammography is a useful method for intraoperative determination of adequacy of excision.

METHODS

A retrospective review was performed on patients who underwent wire-localized partial mastectomy for invasive cancer in our Breast Center from 2000 to 2001. Two-view specimen mammography reports were compared to the pathologic evaluation.

RESULTS

Eighty-eight of 93 patients (95%) had complete primary excision. Sixteen patients had additional margins excised at the time of the initial operation based on specimen mammogram. Six patients would have had positive margins had additional excision at the primary surgery not been performed.

CONCLUSIONS

Specimen mammography can help reduce reoperation rate by identifying patients who need additional margin excision at the time of initial surgery for breast conservation therapy. Using two-view specimen mammography, our reoperation rate was reduced from 12% to 5%.

Intra-operative specimen analysis using faxitron microradiography for excision of mammographically suspicious, non-palpable breast lesions

Recent advances in digital imaging have made Faxitron microradiography an attractive alternative to intra-operative conventional specimen radiography (CSR) for the excision of wire-localized breast lesions. Faxitron specimen analysis time, usefulness of digital image manipulation and re-excision rates were evaluated in comparison to CSR in 299 consecutive wire-localized excisions for mammographically suspicious non-palpable breast lesions (172 procedures with Faxitron, 127 with CSR) in a non-randomized study. The corresponding mean operation times were 34.7 vs. 42.7 min and the respective re-excision rates were 19.8% vs. 31.5% (no significant difference on chi analysis P < 0.1). Faxitron digital image manipulation led to cavity biopsies in 50% (60/121) of the cancer excisions. In 19 of these (16%), histological excision margins were converted from incomplete to complete. The shorter Faxitron mean operating time enables an additional wire-localized operation per theatre list. Digital imaging guides the surgeon for additional cavity biopsies, resulting in re-excision rates as good as CSR.

Neoadjuvant hormonal therapy for ductal carcinoma in situ: trial design and preliminary results

For some women, the treatment for ductal carcinoma in situ (DCIS) may be even more aggressive than treatments undertaken for early-stage invasive disease. Expectant management is not a tenable alternative, given that in a significant percentage of patients, DCIS eventually progresses to invasive cancer. Nevertheless, if this progression could be halted or reversed with primary medical therapy alone, a significant portion of the 50,000 women diagnosed with DCIS in the United States annually could potentially avoid the morbidity of surgery and radiation for this disease. The most promising therapeutic candidates in this regard are those treatments targeting hormone receptors on breast cancer cells. We have initiated a clinical trial of neoadjuvant hormonal therapy for women with hormone receptor-positive DCIS. We discuss the clinical rationale and study design for this trial and present our preliminary results.

Surgical use of breast ultrasound

As surgeons become increasingly more comfortable in interpreting and using US to determine benignancy and malignancy of breast lesions, use of US-guided needle biopsy. US-guided lumpectomy, percutaneous excision of benign masses, and ablation of cancers will become routine.

Magnetic resonance imaging in patients diagnosed with ductal carcinoma-in-situ: value in the diagnosis of residual disease, occult invasion, and multicentricity

BACKGROUND

Although magnetic resonance imaging (MRI) has been shown to be a sensitive imaging tool for invasive breast cancers, its utility in ductal carcinoma-in-situ (DCIS) of the breast remains controversial. We studied the performance of MRI in patients with known DCIS for assessment of residual disease, occult invasion, and multicentricity to determine the clinical role of MRI in this setting.

METHODS

Fifty-one patients with biopsy-proven DCIS underwent contrast-enhanced MRI before surgical treatment. Pre-, early post-, and late postcontrast three-dimensional gradient echo images were obtained and MRI findings were correlated with histopathology. When possible, the performance of MRI and mammography was compared.

RESULTS

The accuracy of MRI was 88% in predicting residual disease, 82% in predicting invasive disease, and 90% in predicting multicentricity. The performance of MRI was equivalent in the core biopsy group when compared with the surgical biopsy group. For occult invasion only, MRI and mammography were equivalent. However, overall, MRI was more sensitive and had a higher negative predictive value than mammography.

CONCLUSIONS

MRI of DCIS can serve as a useful adjunct to mammography by providing a more accurate assessment of the extent of residual or multicentric disease. The performance of MRI is not significantly affected by antecedent surgical excision. MRI may be particularly valuable if preoperatively negative.

Significance and assessment of margin status in ductal carcinoma in situ of the breast

This article reviews practical and theoretical aspects of margin assessment for surgically excised ductal carcinoma in situ of the breast. Different methods of assessing surgical margins are discussed, including selected tangential sections, the margin shaving, and cavity peel methods. Criteria for margin adequacy and the relevance of margin status in the selection of cases for breast conservation are discussed in the context of other important risk factors for local failure.

Bracketing wires for preoperative breast needle localization

OBJECTIVE

The purpose of this study was to evaluate the outcomes of bracketing wire placement during preoperative breast needle localization.

SUBJECTS AND METHODS

We prospectively examined mammograms of 1057 consecutive lesions that had preoperative needle localization and surgical excision and classified the lesions according to Breast Imaging Reporting and Data System (BI-RADS) final assessment categories. Bracketing wires, defined as multiple wires placed to delineate the boundaries of a single lesion, were used in 103 (9.7%) of 1057 lesions. Medical records, imaging studies, and histologic findings in these 103 lesions were reviewed.

RESULTS

Of 103 bracketed lesions, median lesion size was 3.5 cm (range, 1.5-9.5 cm). Ninety-three lesions (90.3%) contained calcifications; 65 lesions (63.1%) were BI-RADS category 5 (highly suggestive of malignancy); and 33 lesions (32.0%) were percutaneously proven cancers. The median number of wires placed was two (range, 2-5). Surgical histologic findings were carcinoma in 75 lesions (72.8%), atypical hyperplasia in eight lesions (7.8%), and benign in 20 lesions (19.4%). Of 42 calcific lesions that were bracketed and had postoperative mammograms available for review, complete removal of suspicious calcifications was accomplished in 34 (81.0%). Of 75 cancers that were bracketed, clear histologic margins of resection were obtained in 33 (44.0%).

CONCLUSION

Bracketing wires were used during preoperative needle localization primarily for larger calcific lesions that were proven cancers or were highly suggestive of malignancy (BI-RADS category 5). Bracketing wires may assist the surgeon in achieving complete excision of calcifications, but bracketing wires do not ensure clear histologic margins of resection.

Wire-guided excision of non-palpable breast cancer: determinants and correlations between radiologic and histologic margins and residual disease in re-excisions

In cases of wire-guided excision of non-palpable breast cancer (WGE), data concerning the determinants and correlations between radiologic and histologic margins and residual cancer in re-excisions are sparse. A total of 21 variables in 66 WGE followed by 49 re-excisions were prospectively analyzed. In multivariate analysis, only large mammographic lesions were clearly related to positive margins in specimen radiography (P<0.05). Multifocality (P<0.001), large pathologic size (P<0.05) and superficial excision (P<0.05) were related to positive histologic margins and multifocality (P=0.001) to residual disease in re-excisions. The sensitivity, specificity and positive predictive values of specimen radiography for predicting histologic margins were 33%, 79% and 53%, and those for predicting residual disease 30%, 80% and 38%, respectively. The ability of histologic margins to predict residual disease was 91%, 58% and 38%, respectively. In WGE, large mammographic lesions carry a significant risk for radiologically incomplete excision, while pathologically large and multifocal tumors may be histologically incompletely excised, especially if the excision does not extend down to the pectoral fascia. The excision sites of multifocal tumors should be re-excised because of the considerable risk of residual disease. The radiologic and histologic margins of the specimen may be misleading.