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Kim Y, Ganduglia-Cazaban C, Tamirisa N, Lucci A, Krause TM. Contemporary Analysis of Reexcision and Conversion to Mastectomy Rates and Associated Healthcare Costs for Women Undergoing Breast-Conserving Surgery. Ann Surg Oncol 2024; 31:3649-3660. [PMID: 38319511 PMCID: PMC11076367 DOI: 10.1245/s10434-024-14902-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 01/02/2024] [Indexed: 02/07/2024]
Abstract
PURPOSE This study was designed to provide a comprehensive and up-to-date understanding of population-level reoperation rates and incremental healthcare costs associated with reoperation for patients who underwent breast-conserving surgery (BCS). METHODS This is a retrospective cohort study using Merative™ MarketScan® commercial insurance data and Medicare 5% fee-for-service claims data. The study included females aged 18-64 years in the commercial cohort and females aged 18 years and older in the Medicare cohort, who underwent initial BCS for breast cancer in 2017-2019. Reoperation rates within a year of the initial BCS and overall 1-year healthcare costs stratified by reoperation status were measured. RESULTS The commercial cohort included 17,129 women with a median age of 55 (interquartile range [IQR] 49-59) years, and the Medicare cohort included 6977 women with a median age of 73 (IQR 69-78) years. Overall reoperation rates were 21.1% (95% confidence interval [CI] 20.5-21.8%) for the commercial cohort and 14.9% (95% CI 14.1-15.7%) for the Medicare cohort. In both cohorts, reoperation rates decreased as age increased, and conversion to mastectomy was more prevalent among younger women in the commercial cohort. The mean healthcare costs during 1 year of follow-up from the initial BCS were $95,165 for the commercial cohort and $36,313 for the Medicare cohort. Reoperations were associated with 24% higher costs in both the commercial and Medicare cohorts, which translated into $21,607 and $8559 incremental costs, respectively. CONCLUSIONS The rates of reoperation after BCS have remained high and have contributed to increased healthcare costs. Continuing efforts to reduce reoperation need more attention.
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Affiliation(s)
- Youngran Kim
- Department of Management, Policy and Community Health, The University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA.
| | - Cecilia Ganduglia-Cazaban
- Department of Management, Policy and Community Health, The University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
| | - Nina Tamirisa
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anthony Lucci
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Trudy Millard Krause
- Department of Management, Policy and Community Health, The University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
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Bhimani F, Lin S, McEvoy M, Cavalli A, Obaid L, Chen Y, Gupta A, Pastoriza J, Shihabi A, Feldman S. Does Nipple-Ward Positive Margin Contribute to a Higher Rate of Re-Excision Procedures After a Lumpectomy with Pathology-Confirmed Positive Margins? A Retrospective Study. Breast Cancer (Dove Med Press) 2024; 16:41-50. [PMID: 38405107 PMCID: PMC10894517 DOI: 10.2147/bctt.s425863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 11/10/2023] [Indexed: 02/27/2024]
Abstract
Background Positive margins on lumpectomy specimens are associated with a twofold increased risk of local breast tumor recurrence. Prior literature has demonstrated various techniques and modalities for assessing margin status to reduce re-excision rates. However, there is paucity of literature analyzing which margin contributes to the highest re-excision rates. Therefore, the primary aim of the study was to investigate whether the nipple-ward margins resulted in a higher rate of re-excision in our patient population. Methods A retrospective chart review was performed on patients who had re-excision surgery. Nipple-ward margin was identified by correlating radiological and pathological reports. A cut-off of more than 25% was used to demonstrate correlation between nipple-ward margin and re-excision rate. Results A total of 98 patients' data were analyzed, with 41 (41.8%), 14 (14.3%), 5 (5.1%), and 38 (38.8%) diagnosed with DCIS, IDC, ILC, and mixed pathology on their margins, respectively. Overall, 48% (n=47) of the positive margins were nipple-ward, with 44.7% (n=21) reporting DCIS. Upon stratification, 45 (45.9%) cases were single-margin positive, with 26 (57.8%) being nipple-ward. Furthermore, the remaining 53 (54.1%) patients had multiple positive margins, with 21 (39.6.7%) nipple-ward cases. Conclusion Positive nipple-ward margins significantly contribute to a higher re-excision rate p < 0.001; 48% of re-excision surgeries had positive nipple-ward margins, and 57.8% of positive single-margin cases were nipple-ward. Taking an additional shave during initial lumpectomy decreases re-excision rates. However, planning a lumpectomy procedure with a more elliptical rather than a spherical resection with additional cavity shave (ie, larger volume) in the nipple-ward direction and minimizing the remaining cavity shaves so the total volume resected remains unchanged. Nevertheless, future studies with larger sample sizes are required to bolster our findings.
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Affiliation(s)
- Fardeen Bhimani
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, New York, USA
| | - Sophie Lin
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, New York, USA
| | - Maureen McEvoy
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, New York, USA
- Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Liane Obaid
- Albert Einstein College of Medicine, Bronx, New York, USA
| | - Yu Chen
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, New York, USA
| | - Anjuli Gupta
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, New York, USA
- Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jessica Pastoriza
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, New York, USA
- Albert Einstein College of Medicine, Bronx, New York, USA
| | - Areej Shihabi
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, New York, USA
| | - Sheldon Feldman
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, New York, USA
- Albert Einstein College of Medicine, Bronx, New York, USA
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Chen KA, Kirchoff KE, Butler LR, Holloway AD, Kapadia MR, Kuzmiak CM, Downs-Canner SM, Spanheimer PM, Gallagher KK, Gomez SM. Analysis of Specimen Mammography with Artificial Intelligence to Predict Margin Status. Ann Surg Oncol 2023; 30:7107-7115. [PMID: 37563337 PMCID: PMC10592216 DOI: 10.1245/s10434-023-14083-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/17/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Intraoperative specimen mammography is a valuable tool in breast cancer surgery, providing immediate assessment of margins for a resected tumor. However, the accuracy of specimen mammography in detecting microscopic margin positivity is low. We sought to develop an artificial intelligence model to predict the pathologic margin status of resected breast tumors using specimen mammography. METHODS A dataset of specimen mammography images matched with pathologic margin status was collected from our institution from 2017 to 2020. The dataset was randomly split into training, validation, and test sets. Specimen mammography models pretrained on radiologic images were developed and compared with models pretrained on nonmedical images. Model performance was assessed using sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC). RESULTS The dataset included 821 images, and 53% had positive margins. For three out of four model architectures tested, models pretrained on radiologic images outperformed nonmedical models. The highest performing model, InceptionV3, showed sensitivity of 84%, specificity of 42%, and AUROC of 0.71. Model performance was better among patients with invasive cancers, less dense breasts, and non-white race. CONCLUSIONS This study developed and internally validated artificial intelligence models that predict pathologic margins status for partial mastectomy from specimen mammograms. The models' accuracy compares favorably with published literature on surgeon and radiologist interpretation of specimen mammography. With further development, these models could more precisely guide the extent of resection, potentially improving cosmesis and reducing reoperations.
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Affiliation(s)
- Kevin A Chen
- Division of Surgical Oncology, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kathryn E Kirchoff
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Logan R Butler
- Division of Surgical Oncology, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Alexa D Holloway
- Division of Surgical Oncology, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Muneera R Kapadia
- Division of Surgical Oncology, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Cherie M Kuzmiak
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stephanie M Downs-Canner
- Department of Surgery, Breast Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Phillip M Spanheimer
- Division of Surgical Oncology, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kristalyn K Gallagher
- Division of Surgical Oncology, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Shawn M Gomez
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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4
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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5
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Chen KA, Kirchoff KE, Butler LR, Holloway AD, Kapadia MR, Gallagher KK, Gomez SM. Computer Vision Analysis of Specimen Mammography to Predict Margin Status. medRxiv 2023:2023.03.06.23286864. [PMID: 36945565 PMCID: PMC10029028 DOI: 10.1101/2023.03.06.23286864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
Intra-operative specimen mammography is a valuable tool in breast cancer surgery, providing immediate assessment of margins for a resected tumor. However, the accuracy of specimen mammography in detecting microscopic margin positivity is low. We sought to develop a deep learning-based model to predict the pathologic margin status of resected breast tumors using specimen mammography. A dataset of specimen mammography images matched with pathology reports describing margin status was collected. Models pre-trained on radiologic images were developed and compared with models pre-trained on non-medical images. Model performance was assessed using sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC). The dataset included 821 images and 53% had positive margins. For three out of four model architectures tested, models pre-trained on radiologic images outperformed domain-agnostic models. The highest performing model, InceptionV3, showed a sensitivity of 84%, a specificity of 42%, and AUROC of 0.71. These results compare favorably with the published literature on surgeon and radiologist interpretation of specimen mammography. With further development, these models could assist clinicians with identifying positive margins intra-operatively and decrease the rate of positive margins and re-operation in breast-conserving surgery.
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Affiliation(s)
- Kevin A Chen
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Kathryn E Kirchoff
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Logan R Butler
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Alexa D Holloway
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Muneera R Kapadia
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Shawn M Gomez
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Banys-Paluchowski M, Rubio IT, Ditsch N, Krug D, Gentilini OD, Kühn T. Real de-escalation or escalation in disguise? Breast 2023; 69:249-257. [PMID: 36898258 PMCID: PMC10017412 DOI: 10.1016/j.breast.2023.03.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/03/2023] [Indexed: 03/06/2023] Open
Abstract
The past two decades have seen an unprecedented trend towards de-escalation of surgical therapy in the setting of early BC, the most prominent examples being the reduction of re-excision rates for close surgical margins after breast-conserving surgery and replacing axillary lymph node dissection by less radical procedures such as sentinel lymph node biopsy (SLNB). Numerous studies confirmed that reducing the extent of surgery in the upfront surgery setting does not impact locoregional recurrences and overall outcome. In the setting of primary systemic treatment, there is an increased use of less invasive staging strategies reaching from SLNB and targeted lymph node biopsy (TLNB) to targeted axillary dissection (TAD). Omission of any axillary surgery in the presence of pathological complete response in the breast is currently being investigated in clinical trials. On the other hand, concerns have been raised that surgical de-escalation might induce an escalation of other treatment modalities such as radiation therapy. Since most trials on surgical de-escalation did not include standardized protocols for adjuvant radiotherapy, it remains unclear, whether the effect of surgical de-escalation was valid in itself or if radiotherapy compensated for the decreased surgical extent. Uncertainties in scientific evidence may therefore lead to escalation of radiotherapy in some settings of surgical de-escalation. Further, the increasing rate of mastectomies including contralateral procedures in patients without genetic risk is alarming. Future studies of locoregional treatment strategies need to include an interdisciplinary approach to integrate de-escalation approaches combining surgery and radiotherapy in a way that promotes optimal quality of life and shared decision-making.
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Affiliation(s)
- Maggie Banys-Paluchowski
- Department of Obstetrics and Gynecology, University Hospital of Schleswig Holstein, Campus Lübeck, Lübeck, Germany
| | - Isabel T Rubio
- Breast Surgical Unit, Clínica Universidad de Navarra, Madrid, Spain
| | - Nina Ditsch
- Department of Obstetrics and Gynecology, University Hospital Augsburg, Augsburg, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital of Schleswig Holstein, Campus Kiel, Kiel, Germany
| | | | - Thorsten Kühn
- Department of Gynecology and Obstetrics, Interdisciplinary Breast Center, Die Filderklinik, Filderstadt, Germany.
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7
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Varsanik MA, Shubeck SP. De-Escalating Breast Cancer Therapy. Surg Clin North Am 2023; 103:83-92. [DOI: 10.1016/j.suc.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Richey WL, Heiselman JS, Ringel MJ, Meszoely IM, Miga MI. Computational Imaging to Compensate for Soft-Tissue Deformations in Image-Guided Breast Conserving Surgery. IEEE Trans Biomed Eng 2022; 69:3760-3771. [PMID: 35604993 PMCID: PMC9811993 DOI: 10.1109/tbme.2022.3177044] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE During breast conserving surgery (BCS), magnetic resonance (MR) images aligned to accurately display intraoperative lesion locations can offer improved understanding of tumor extent and position relative to breast anatomy. Unfortunately, even under consistent supine conditions, soft tissue deformation compromises image-to-physical alignment and results in positional errors. METHODS A finite element inverse modeling technique has been developed to nonrigidly register preoperative supine MR imaging data to the surgical scene for improved localization accuracy during surgery. Registration is driven using sparse data compatible with acquisition during BCS, including corresponding surface fiducials, sparse chest wall contours, and the intra-fiducial skin surface. Deformation predictions were evaluated at surface fiducial locations and subsurface tissue features that were expertly identified and tracked. Among n = 7 different human subjects, an average of 22 ± 3 distributed subsurface targets were analyzed in each breast volume. RESULTS The average target registration error (TRE) decreased significantly when comparing rigid registration to this nonrigid approach (10.4 ± 2.3 mm vs 6.3 ± 1.4 mm TRE, respectively). When including a single subsurface feature as additional input data, the TRE significantly improved further (4.2 ± 1.0 mm TRE), and in a region of interest within 15 mm of a mock biopsy clip TRE was 3.9 ± 0.9 mm. CONCLUSION These results demonstrate accurate breast deformation estimates based on sparse-data-driven model predictions. SIGNIFICANCE The data suggest that a computational imaging approach can account for image-to-surgery shape changes to enhance surgical guidance during BCS.
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Schumacher JR, Lawson EH, Kong AL, Weber JJ, May J, Landercasper J, Hanlon B, Marka N, Venkatesh M, Cartmill RS, Pavuluri Quamme S, Nikolay C, Greenberg CC. A Statewide Approach to Reducing Re-excision Rates for Women With Breast-conserving Surgery. Ann Surg 2022; 276:665-672. [PMID: 35837946 PMCID: PMC9529150 DOI: 10.1097/sla.0000000000005590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Test the effectiveness of benchmarked performance reports based on existing discharge data paired with a statewide intervention to implement evidence-based strategies on breast re-excision rates. BACKGROUND Breast-conserving surgery (BCS) is a common breast cancer surgery performed in a range of hospital settings. Studies have demonstrated variations in post-BCS re-excision rates, identifying it as a high-value improvement target. METHODS Wisconsin Hospital Association discharge data (2017-2019) were used to compare 60-day re-excision rates following BCS for breast cancer. The analysis estimated the difference in the average change preintervention to postintervention between Surgical Collaborative of Wisconsin (SCW) and nonparticipating hospitals using a logistic mixed-effects model with repeated measures, adjusting for age, payer, and hospital volume, including hospitals as random effects. The intervention included 5 collaborative meetings in 2018 to 2019 where surgeon champions shared guideline updates, best practices/challenges, and facilitated action planning. Confidential benchmarked performance reports were provided. RESULTS In 2017, there were 3692 breast procedures in SCW and 1279 in nonparticipating hospitals; hospital-level re-excision rates ranged from 5% to >50%. There was no statistically significant baseline difference in re-excision rates between SCW and nonparticipating hospitals (16.1% vs. 17.1%, P =0.47). Re-excision significantly decreased for SCW but not for nonparticipating hospitals (odds ratio=0.69, 95% confidence interval=0.52-0.91). CONCLUSIONS Benchmarked performance reports and collaborative quality improvement can decrease post-BCS re-excisions, increase quality, and decrease costs. Our study demonstrates the effective use of administrative data as a platform for statewide quality collaboratives. Using existing data requires fewer resources and offers a new paradigm that promotes participation across practice settings.
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Affiliation(s)
| | - Elise H Lawson
- Department of Surgery, University of Wisconsin-Madison, Madison, WI
| | - Amanda L Kong
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | | | - Jeanette May
- Department of Surgery, University of Wisconsin-Madison, Madison, WI
| | | | - Bret Hanlon
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI
| | - Nicholas Marka
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN
| | - Manasa Venkatesh
- Department of Surgery, University of Wisconsin-Madison, Madison, WI
| | - Randi S Cartmill
- Department of Surgery, University of Wisconsin-Madison, Madison, WI
| | | | - Connor Nikolay
- Department of Surgery, University of Wisconsin-Madison, Madison, WI
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Banys-Paluchowski M, Rubio IT, Karadeniz Cakmak G, Esgueva A, Krawczyk N, Paluchowski P, Gruber I, Marx M, Brucker SY, Bündgen N, Kühn T, Rody A, Hanker L, Hahn M. Intraoperative Ultrasound-Guided Excision of Non-Palpable and Palpable Breast Cancer: Systematic Review and Meta-Analysis. Ultraschall Med 2022; 43:367-379. [PMID: 35760079 DOI: 10.1055/a-1821-8559] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Wire-guided localization (WGL) is the most frequently used localization technique in non-palpable breast cancer (BC). However, low negative margin rates, patient discomfort, and the possibility of wire dislocation have been discussed as potential disadvantages, and re-operation due to positive margins may increase relapse risk. Intraoperative ultrasound (IOUS)-guided excision allows direct visualization of the lesion and the resection volume and reduces positive margins in palpable and non-palpable tumors. We performed a systematic review on IOUS in breast cancer and 2 meta-analyses of randomized clinical trials (RCTs). In non-palpable BC, 3 RCTs have shown higher negative margin rates in the IOUS arm compared to WGL. Meta-analysis confirmed a significant difference between IOUS and WGL in terms of positive margins favoring IOUS (risk ratio 4.34, p < 0.0001, I2 = 0%). 41 cohort studies including 3291 patients were identified, of which most reported higher negative margin and lower re-operation rates if IOUS was used. In palpable BC, IOUS was compared to palpation-guided excision in 3 RCTs. Meta-analysis showed significantly higher rates of positive margins in the palpation arm (risk ratio 2.84, p = 0.0047, I2 = 0%). In 13 cohort studies including 942 patients with palpable BC, negative margin rates were higher if IOUS was used, and tissue volumes were higher in palpation-guided cohorts in most studies. IOUS is a safe noninvasive technique for the localization of sonographically visible tumors that significantly improves margin rates in palpable and non-palpable BC. Surgeons should be encouraged to acquire ultrasound skills and participate in breast ultrasound training.
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Affiliation(s)
- Maggie Banys-Paluchowski
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany
- Medical Faculty, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Isabel T Rubio
- Breast Surgical Unit, Clinica Universidad de Navarra, Madrid, Spain
| | - Güldeniz Karadeniz Cakmak
- General Surgery Department, Breast and Endocrine Unit, Zonguldak BEUN The School of Medicine, Kozlu/Zonguldak, Turkey
| | - Antonio Esgueva
- Breast Surgical Unit, Clinica Universidad de Navarra, Madrid, Spain
| | - Natalia Krawczyk
- Department of Obstetrics and Gynecology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Peter Paluchowski
- Department of Gynecology and Obstetrics, Regio Klinikum Pinneberg, Pinneberg, Germany
| | - Ines Gruber
- Department for Women's Health, University of Tübingen, Tübingen, Germany
| | - Mario Marx
- Department of Plastic, Reconstructive and Breast Surgery, Elblandklinikum Radebeul, Radebeul, Germany
| | - Sara Y Brucker
- Department for Women's Health, University of Tübingen, Tübingen, Germany
| | - Nana Bündgen
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Thorsten Kühn
- Department of Gynecology and Obstetrics, Klinikum Esslingen, Esslingen, Germany
| | - Achim Rody
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Lars Hanker
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Markus Hahn
- Department for Women's Health, University of Tübingen, Tübingen, Germany
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Abstract
INTRODUCTION As breast cancer treatment options have multiplied and biologic diversity within breast cancer has been recognized, the use of the same treatment strategies for patients with early-stage and favorable disease, and for those with biologically aggressive disease, has been questioned. In addition, as patient-reported outcome measures have called attention to the morbidity of many common treatments, and as the cost of breast cancer care has continued to increase, reduction in the overtreatment of breast cancer has assumed increasing importance. AREAS COVERED Here we review selected aspects of surgery, radiation oncology, and medical oncology for which scientific evidence supports de-escalation for invasive carcinoma and ductal carcinoma in situ, and assess strategies to address overtreatment. EXPERT OPINION The problems of breast cancer overtreatment we face today are based on improved understanding of the biology of breast cancer and abandonment of the 'one-size-fits-all' approach. As breast cancer care becomes increasingly complex, and as our knowledge base continues to increase exponentially, these problems will only be magnified in the future. To continue progress, the move must be made from advocating the maximum-tolerated treatment to advocating the minimum-effective one.
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Affiliation(s)
- Linda M Pak
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York
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Shubeck SP, Morrow M, Dossett LA. De-escalation in breast cancer surgery. NPJ Breast Cancer 2022; 8:25. [PMID: 35197478 DOI: 10.1038/s41523-022-00383-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 01/14/2022] [Indexed: 11/17/2022] Open
Abstract
In recent years, several trials of breast cancer treatment have failed to demonstrate a survival benefit for some previously routine surgical therapies in selected patient groups. As each of these therapeutic approaches has been deemed of low value deimplementation has varied significantly. This demonstrates that effective de-escalation in breast cancer surgery relies on more than the availability of data from randomized controlled trials and other high-quality evidence, but is also influenced by various stakeholders, social expectations, and environmental contexts.
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13
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Ellsworth BL, Metz AK, Mott NM, Kazemi R, Stover M, Hughes T, Dossett LA. Review of Cancer-Specific Quality Measures Promoting the Avoidance of Low-Value Care. Ann Surg Oncol 2022; 29:3750-3762. [DOI: 10.1245/s10434-021-11303-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 12/18/2021] [Indexed: 12/28/2022]
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14
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Li L, Zhang Q, Qian C, Lin H. Impact of Preoperative Magnetic Resonance Imaging on Surgical Outcomes in Women with Invasive Breast Cancer: A Systematic Review and Meta-Analysis. Int J Clin Pract 2022; 2022:6440952. [PMID: 36081810 PMCID: PMC9436630 DOI: 10.1155/2022/6440952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/02/2022] [Accepted: 08/06/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Currently, whether magnetic resonance imaging (MRI) should be routinely applied to patients with breast cancer before surgery remains controversial. A pooled analysis of the association between preoperative MRI and surgical outcomes in female patients with newly diagnosed invasive breast cancer was conducted to provide evidence-based medicine for clinical practice. METHODS Three independent researchers searched the following databases: PubMed, Medline, Embase, Ovid, Cochrane Library, and Web of Science from inception to April 2022. Literature was included and excluded according to Cochrane's principles. The basic information from eligible documents was extracted. Systematic evaluation and meta-analysis were performed, and the odds ratio (OR) was analyzed by the random-effect model. The quality of the literature was assessed using the modified Jadad scale and the Newcastle-Ottawa (NOS) mean scale. RESULTS A total of 19 studies were included, including 4 randomized controlled trials and 15 observational comparative studies. Among them, most studies were not limited to a specific pathological type, with the exception of 3 that were limited to invasive lobular carcinoma. The results showed that preoperative MRI examination would significantly reduce the reoperation rate (OR = 0.77, P=0.02) and increase the mastectomy rate (OR = 1.36, P=0.001). In comparison, preoperative MRI did not significantly affect the rate of secondary mastectomy (OR = 0.77, P=0.02), the rate of positive margin (OR = 1.08, P=0.66), the rate of mastectomy (OR = 1.00, P < 0.05), and reoperations (OR = 0.65, P=0.19) in the subgroup analysis of patients with invasive lobular carcinoma. CONCLUSION Available evidence suggests that preoperative MRI examination increases the rate of mastectomy and reduces the rate of reoperations. The results indicate that preoperative MRI examination has the potential to benefit patients with breast cancer, but more high-quality studies are needed for confirmation.
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Affiliation(s)
- Li Li
- Department of Medical Imaging, Haikou Maternal and Child Health Hospital, Haikou 570203, China
| | - Qinghong Zhang
- Department of Breast Surgery, Haikou Maternal and Child Health Hospital, Haikou 570203, China
| | - Chunrui Qian
- Department of Radiology, Haikou Hospital of Traditional Chinese Medicine, Haikou 570216, China
| | - Huien Lin
- Department of Medical Imaging, Haikou Maternal and Child Health Hospital, Haikou 570203, China
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15
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Mrdutt M, Heerdt A, Sevilimedu V, Mamtani A, Barrio A, Morrow M. Margin Width and Local Recurrence in Patients Undergoing Breast Conservation After Neoadjuvant Chemotherapy. Ann Surg Oncol 2022; 29:484-492. [PMID: 34331159 PMCID: PMC9398668 DOI: 10.1245/s10434-021-10533-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/10/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND A margin of "no ink on tumor" has been established for primary breast conservation therapy (BCT), but the appropriate margin following neoadjuvant chemotherapy (NAC) remains controversial. We examined the impact of margin width on ipsilateral breast tumor recurrence (IBTR) in the NAC-BCT population. METHODS Consecutive patients receiving NAC-BCT were identified from a prospective database. The associations between clinicopathologic characteristics, margin width, and isolated IBTR were evaluated. RESULTS From 2013 to 2019 we identified 582 patients with 586 tumors who received NAC-BCT. The median age of the cohort was 54 years (IQR 45, 62); 84% of patients had cT1/T2 tumors and 61% were clinically node positive. The majority of tumors were HER2+ (38%) or triple negative (TN) (31%). Pathologic complete response was observed in 29%. Margin width was > 2 mm in 517 tumors (88%) and ≤ 2 mm in 69 (12%). At a median follow-up of 39 months, 14 patients had IBTR as a first event, with 64% occurring within 24 months of surgery. The 4-year IBTR rate was 2% (95% CI 1-4%), and there was no difference based on margin width (3% ≤ 2 mm vs 2% > 2 mm; p = not significant). On univariate analysis, clinical and pathologic T stage and receptor subtype, but not margin width, were associated with IBTR (p < 0.05). On multivariable analysis, TN subtype and higher pathologic T stage were associated with isolated IBTR (both p < 0.05). CONCLUSION Pathologic features and tumor biology, not margin width, were associated with IBTR in NAC-BCT patients.
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Affiliation(s)
- Mary Mrdutt
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY,Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alexandra Heerdt
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY,Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Varadan Sevilimedu
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY,Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Anita Mamtani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY,Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andrea Barrio
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY,Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY,Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
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16
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Lepomäki M, Karhunen-Enckell U, Tuominen J, Kronqvist P, Oksala N, Murtola T, Roine A. Tumor margins that lead to reoperation in breast cancer: A retrospective register study of 4,489 patients. J Surg Oncol 2021; 125:577-588. [PMID: 34779520 PMCID: PMC9298886 DOI: 10.1002/jso.26749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 10/15/2021] [Accepted: 11/04/2021] [Indexed: 11/15/2022]
Abstract
Background and Objectives Optimal margins for ductal carcinoma in situ (DCIS) remain controversial in breast‐conserving surgery (BCS) and mastectomy. We examine the association of positive margins, reoperations, DCIS and age. Methods A retrospective study of histopathological reports (4489 patients). Margin positivity was defined as ink on tumor for invasive carcinoma. For DCIS, we applied 2 mm anterior and side margin thresholds, and ink on tumor in the posterior margin. Results The incidence of positive side margins was 20% in BCS and 5% in mastectomies (p < 0.001). Of these patients, 68% and 14% underwent a reoperation (p < 0.001). After a positive side margin in BCS, the reoperation rates according to age groups were 74% (<49), 69% (50–64), 68% (65–79), and 42% (80+) (p = 0.013). Of BCS patients with invasive carcinoma in the side margin, 73% were reoperated on. A reoperation was performed in 70% of patients with a close (≤1 mm) DCIS side margin, compared to 43% with a wider (1.1–2 mm) margin (p = 0.002). The reoperation rates were 55% in invasive carcinoma with close DCIS, 66% in close extensive intraductal component (EIC), and 83% in close pure DCIS (p < 0.001). Conclusions Individual assessment as opposed to rigid adherence to guidelines was used in the decision on reoperation.
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Affiliation(s)
- Maiju Lepomäki
- Surgery, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Ulla Karhunen-Enckell
- Surgery, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Surgery, Tampere University Hospital, Tampere, Finland
| | - Jalmari Tuominen
- Surgery, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | | | - Niku Oksala
- Surgery, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Vascular surgery, Vascular Centre, Tampere University Hospital, Tampere, Finland
| | - Teemu Murtola
- Surgery, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Urology, Tays Cancer Center, Tampere University Hospital, Tampere, Finland.,Department of Surgery, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Antti Roine
- Surgery, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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17
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Simpson D, Allan J, McFall B. Radiological Underestimation of Tumor Size Influences the Success Rate of Re-Excision after Breast-conserving Surgery. Eur J Breast Health 2021; 17:363-370. [PMID: 34651116 DOI: 10.4274/ejbh.galenos.2021.2021-4-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 07/04/2021] [Indexed: 12/01/2022]
Abstract
Objective Failure to achieve adequate margins after breast-conserving surgery often leads to re-excision, either by repeat breast-conserving surgery (BCS) or by mastectomy. Despite the high frequency of this problem, the success rate of achieving adequate margins by repeat BCS is not well documented. The objective of this study was to determine the success rate of repeat BCS and identify the factors influencing that rate. Materials and Methods A retrospective review was performed of all women undergoing repeat BCS for inadequate margins after initial BCS in our breast unit between 2013 and 2019. Univariate and multivariate analyses were carried out to identify the factors influencing how often adequate margins were achieved after repeat BCS. Results One hundred fifty-four patients underwent repeat BCS after initially inadequate margins, of which adequate margins were achieved in 82%. Patients with successful repeat BCS had smaller tumors, had less underestimation of tumor size on imaging, and were less likely to have had cavity shaves taken at their initial BCS. A tumor size more than 50% larger than predicted by imaging was independently associated with failure of repeat BCS in multivariate analysis (odds ratio: 3.6, 95% CI: 1.41-9.20, p = 0.007). Underestimation of tumor size by imaging was commoner and more extensive in patients with larger tumors and those with ductal carcinoma in situ. Conclusion Re-excision by cavity shaves has a high success rate and should be offered to all patients who are deemed suitable for the procedure. Patients whose tumors are more than 50% larger than predicted by imaging should be counseled about the higher risk of failure.
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Affiliation(s)
- Duncan Simpson
- Breast Unit, Antrim Area Hospital, Bush Road, Antrim, Northern Ireland, United Kingdom
| | - Jennifer Allan
- Breast Unit, Antrim Area Hospital, Bush Road, Antrim, Northern Ireland, United Kingdom
| | - Brendan McFall
- Breast Unit, Antrim Area Hospital, Bush Road, Antrim, Northern Ireland, United Kingdom
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18
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Philpot S, Youl PH, Harden H, Morris M, Furnival C, Dunn N, Moore J, Theile DE. Development and implementation of a population-based breast cancer quality index in Queensland, Australia. J Cancer Policy 2021; 29:100291. [DOI: 10.1016/j.jcpo.2021.100291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 05/16/2021] [Accepted: 05/26/2021] [Indexed: 11/28/2022]
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19
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Ottolino-Perry K, Shahid A, DeLuca S, Son V, Sukhram M, Meng F, Liu ZA, Rapic S, Anantha NT, Wang SC, Chamma E, Gibson C, Medeiros PJ, Majeed S, Chu A, Wignall O, Pizzolato A, Rosen CF, Teene LL, Starr-Dunham D, Kulbatski I, Panzarella T, Done SJ, Easson AM, Leong WL, DaCosta RS. Intraoperative fluorescence imaging with aminolevulinic acid detects grossly occult breast cancer: a phase II randomized controlled trial. Breast Cancer Res 2021; 23:72. [PMID: 34253233 DOI: 10.1186/s13058-021-01442-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 05/25/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Re-excision due to positive margins following breast-conserving surgery (BCS) negatively affects patient outcomes and healthcare costs. The inability to visualize margin involvement is a significant challenge in BCS. 5-Aminolevulinic acid hydrochloride (5-ALA HCl), a non-fluorescent oral prodrug, causes intracellular accumulation of fluorescent porphyrins in cancer cells. This single-center Phase II randomized controlled trial evaluated the safety, feasibility, and diagnostic accuracy of a prototype handheld fluorescence imaging device plus 5-ALA for intraoperative visualization of invasive breast carcinomas during BCS. METHODS Fifty-four patients were enrolled and randomized to receive no 5-ALA or oral 5-ALA HCl (15 or 30 mg/kg). Forty-five patients (n = 15/group) were included in the analysis. Fluorescence imaging of the excised surgical specimen was performed, and biopsies were collected from within and outside the clinically demarcated tumor border of the gross specimen for blinded histopathology. RESULTS In the absence of 5-ALA, tissue autofluorescence imaging lacked tumor-specific fluorescent contrast. Both 5-ALA doses caused bright red tumor fluorescence, with improved visualization of tumor contrasted against normal tissue autofluorescence. In the 15 mg/kg 5-ALA group, the positive predictive value (PPV) for detecting breast cancer inside and outside the grossly demarcated tumor border was 100.0% and 55.6%, respectively. In the 30 mg/kg 5-ALA group, the PPV was 100.0% and 50.0% inside and outside the demarcated tumor border, respectively. No adverse events were observed, and clinical feasibility of this imaging device-5-ALA combination approach was confirmed. CONCLUSIONS This is the first known clinical report of visualization of 5-ALA-induced fluorescence in invasive breast carcinoma using a real-time handheld intraoperative fluorescence imaging device. TRIAL REGISTRATION Clinicaltrials.gov identifier NCT01837225 . Registered 23 April 2013.
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20
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Mason EE, Mattingly E, Herb K, Śliwiak M, Franconi S, Cooley CZ, Slanetz PJ, Wald LL. Concept for using magnetic particle imaging for intraoperative margin analysis in breast-conserving surgery. Sci Rep 2021; 11:13456. [PMID: 34188077 PMCID: PMC8242088 DOI: 10.1038/s41598-021-92644-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 06/11/2021] [Indexed: 12/23/2022] Open
Abstract
Breast-conserving surgery (BCS) is a commonly utilized treatment for early stage breast cancers but has relatively high reexcision rates due to post-surgical identification of positive margins. A fast, specific, sensitive, easy-to-use tool for assessing margins intraoperatively could reduce the need for additional surgeries, and while many techniques have been explored, the clinical need is still unmet. We assess the potential of Magnetic Particle Imaging (MPI) for intraoperative margin assessment in BCS, using a passively or actively tumor-targeted iron oxide agent and two hardware devices: a hand-held Magnetic Particle detector for identifying residual tumor in the breast, and a small-bore MPI scanner for quickly imaging the tumor distribution in the excised specimen. Here, we present both hardware systems and demonstrate proof-of-concept detection and imaging of clinically relevant phantoms.
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Affiliation(s)
- Erica E Mason
- Department of Radiology, A. A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, 02129, USA.
- Harvard-MIT Division of Health Sciences and Technology, Cambridge, MA, 02139, USA.
| | - Eli Mattingly
- Harvard-MIT Division of Health Sciences and Technology, Cambridge, MA, 02139, USA
| | - Konstantin Herb
- Department of Radiology, A. A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, 02129, USA
- Department of Physics, ETH Zurich, Zurich, Switzerland
| | - Monika Śliwiak
- Department of Radiology, A. A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, 02129, USA
| | - Sofia Franconi
- Department of Radiology, A. A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, 02129, USA
| | - Clarissa Zimmerman Cooley
- Department of Radiology, A. A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, 02129, USA
- Harvard Medical School, Boston, MA, 02115, USA
| | - Priscilla J Slanetz
- Department of Radiology, Boston University Medical Center, Boston, MA, 02118, USA
| | - Lawrence L Wald
- Department of Radiology, A. A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, 02129, USA
- Harvard Medical School, Boston, MA, 02115, USA
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21
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Yang M, Hu X, Bao W, Zhang X, Lin Y, Stanton S, Haffty B, Hu W, Kang Y, Wei S, Zhang L. Changing trends and disparities in 5-year overall survival of women with invasive breast cancer in the United States, 1975-2015. Am J Cancer Res 2021; 11:3201-3211. [PMID: 34249455 PMCID: PMC8263668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 05/15/2021] [Indexed: 06/13/2023] Open
Abstract
Relative survival is the ratio of overall survival (OS) over survival of the general population, and widely used in epidemiological studies. But it is artificially higher than OS and thus inferior to OS for cancer prognostication of individual patients. Moreover, trend-changes and disparities in OS of breast cancer are unclear while the relative survival of breast cancer has been reported on a regular basis. Therefore, we estimated trends in age-standardized 5-year OS of invasive breast cancer, using data from the Surveillance, Epidemiology, and End Results (SEER) cancer registry program and piecewise-linear regression models. Among 188,052 women with breast cancer diagnosed during 2007-2010 (SEER-18, 155,515 [79.3%] survived by year 5), the 5-year OS significantly differed by age, histology, tumor grade, tumor stage, hormone receptors, race/ethnicity, insurance status, region, rural-urban continuum and selected county-attributes. Among 469,498 women with breast cancer diagnosed during 1975-2010 (SEER-9) in the U.S., we observed an upward trend in the age-standardized 5-year OS (stage- and race/ethnicity-adjusted annual percentage change = 0.97 [95% CI, 0.76-1.18]). The 36-year trends/slopes in age-standardized 5-year OS of breast cancer differed by histology, tumor grade, stage, race/ethnicity, region and socioeconomic attributes of the patient's residence-county, but not by those of rural-urban continuum. The 3-joinpoint model on the 36-year trend identified significant slope changes in 1983, 1987 and 2000, with the largest slope (2.5%/year) during 1983-1987. In conclusion, we here show trends in the age-standardized 5-year OS among U.S. women with breast cancer changed in diagnosis-years of 1983, 1987 and 2000, and differed by tumor characteristics and race/ethnicity. More efforts are needed to understand the trend changes and to address the OS disparities of breast cancers.
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Affiliation(s)
- Mu Yang
- Department of Pathology, Princeton Medical CenterPlainsboro, NJ, USA
- Department of Pathology, Shanghai General Hospital, Shanghai Jiaotong UniversityShanghai 200080, China
| | - Xin Hu
- Yale Center for Analytical Sciences, School of Public Health, Yale UniversityNew Haven, CT, USA
| | - Wei Bao
- Department of Epidemiology, College of Public Health, University of IowaIowa City, IA, USA
| | - Xinmin Zhang
- Department of Pathology, Cooper University Hospital, Cooper Medical School of Rowan UniversityCamden, NJ, USA
| | - Yong Lin
- Rutgers Cancer Institute of New JerseyNew Brunswick, NJ, USA
- Department of Biostatistics and Epidemiology, School of Public Health, Rutgers UniversityPiscataway, NJ, USA
| | - Sasha Stanton
- Cancer Vaccine Institute, University of WashingtonSeattle, WA, USA
| | - Bruce Haffty
- Rutgers Cancer Institute of New JerseyNew Brunswick, NJ, USA
| | - Wenwei Hu
- Rutgers Cancer Institute of New JerseyNew Brunswick, NJ, USA
| | - Yibin Kang
- Department of Molecular Biology, Princeton UniversityPrinceton, NJ, USA
| | - Shi Wei
- Department of Pathology, University of Alabama at BirminghamBirmingham, AL, USA
| | - Lanjing Zhang
- Department of Pathology, Princeton Medical CenterPlainsboro, NJ, USA
- Rutgers Cancer Institute of New JerseyNew Brunswick, NJ, USA
- Department of Biological Sciences, Rutgers UniversityNewark, NJ, USA
- Department of Chemical Biology, Ernest Mario School of Pharmacy, Rutgers UniversityPiscataway, NJ, USA
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22
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Shen JG, Wang LB, Jiang ZN, Yuan XM, Zhao WH, Shen J. Value of intraoperative frozen section analysis in re-excision margin evaluation in breast-conserving surgery for cancer: a single institution experience. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02952-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
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23
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Abstract
Breast cancer is still the most common cancer worldwide. But the way breast cancer is viewed has changed drastically since its molecular hallmarks were extensively characterised, now including immunohistochemical markers (eg, ER, PR, HER2 [ERBB2], and proliferation marker protein Ki-67 [MKI67]), genomic markers (eg, BRCA1, BRCA2, and PIK3CA), and immunomarkers (eg, tumour-infiltrating lymphocytes and PD-L1). New biomarker combinations are the basis for increasingly complex diagnostic algorithms. Neoadjuvant combination therapy, often including targeted agents, is a standard of care (especially in HER2-positive and triple-negative breast cancer), and the basis for de-escalation of surgery in the breast and axilla and for risk-adapted post-neoadjuvant strategies. Radiotherapy remains an important cornerstone of breast cancer therapy, but de-escalation schemes have become the standard of care. ER-positive tumours are treated with 5-10 years of endocrine therapy and chemotherapy, based on an individual risk assessment. For metastatic breast cancer, standard therapy options include targeted approaches such as CDK4 and CDK6 inhibitors, PI3K inhibitors, PARP inhibitors, and anti-PD-L1 immunotherapy, depending on tumour type and molecular profile. This range of treatment options reflects the complexity of breast cancer therapy today.
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Affiliation(s)
- Sibylle Loibl
- German Breast Group, Neu-Isenburg, Germany; Centre for Haematology and Oncology Bethanien, Frankfurt, Germany.
| | - Philip Poortmans
- Department of Radiation Oncology, Iridium Kankernetwerk, Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Antwerp, Belgium
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Carsten Denkert
- German Breast Group, Neu-Isenburg, Germany; Institute of Pathology, Philipps University of Marburg, Marburg, Germany; University Hospital Marburg, Marburg, Germany
| | - Giuseppe Curigliano
- European Institute of Oncology IRCCS, Milan, Italy; University of Milano, Milan, Italy
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Garzotto F, Comoretto RI, Michieletto S, Franzoso G, Lo Mele M, Gregori D, Bonavina MG, Bozza F, Caumo F, Saibene T. Preoperative non-palpable breast lesion localization, innovative techniques and clinical outcomes in surgical practice: A systematic review and meta-analysis. Breast 2021; 58:93-105. [PMID: 33991806 PMCID: PMC8481910 DOI: 10.1016/j.breast.2021.04.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/31/2021] [Accepted: 04/19/2021] [Indexed: 12/30/2022] Open
Abstract
Pre-operative localization of non-palpable breast lesions with non-wired non-ionizing (NWNI) techniques may improve clinical outcomes as reoperation rate, cosmetic outcome and contribute to organizational aspects improvement in breast-conserving surgery (BCS). However only limited literature is available and clinical studies involving these forefront devices are often small and non-randomized. Furthermore, there is a lack of consensus on free margins and cosmetic outcomes definitions. The objective of the present meta-analysis was to determine the crude clinical outcomes reported for the NWNI techniques on BCS. A literature search was performed of PubMed, Embase and Scopus databases up to February 2021 in order to select all prospective or retrospective clinical trials on pre-operative breast lesion localization done with NWNI devices. All studies were assessed following the PRISMA recommendations. Continuous outcomes were described in averages corrected for sample size, while binomial outcomes were described using the weighted average proportion. Twenty-seven studies with a total of 2103 procedures were identified. The technique is consolidated, showing for both reflectors' positioning and localization nearly the 100% rate of success. The re-excision and clear margins rates were 14% (95% CI, 11-17%) and 87% (80-92%), respectively. Overall, positive margins rates were 12% (8-17%). In studies that compared NWNI and wire localization techniques, positive margin rate is lower for the first techniques (12%, 6-22% vs 17%, 12-23%) and re-excision rate is slightly higher using the latter (13%, 9-19% vs 16%, 13-18%). Pre-operative NWNI techniques are effective in the localization of non-palpable breast lesions and are promising in obtaining clear (or negative) margins minimizing the need for re-excision and improving the cosmetic outcomes. Randomized trials are needed to confirm these findings.
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Affiliation(s)
- Francesco Garzotto
- Breast Radiology Unit, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy.
| | - Rosanna Irene Comoretto
- Department of Cardiac Thoracic Vascular Sciences and Public Health, Unit of Biostatistics, Epidemiology and Public Health, University of Padova, Padova, Italy
| | - Silvia Michieletto
- Breast Surgery Unit, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
| | | | - Marcello Lo Mele
- Department of Medicine (DIMED), Surgical Pathology Unit, University of Padua, Padua, 35121, Italy
| | - Dario Gregori
- Department of Cardiac Thoracic Vascular Sciences and Public Health, Unit of Biostatistics, Epidemiology and Public Health, University of Padova, Padova, Italy
| | | | - Fernando Bozza
- Breast Surgery Unit, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
| | - Francesca Caumo
- Breast Radiology Unit, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
| | - Tania Saibene
- Breast Surgery Unit, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
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25
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Casey DL, Gupta GP, Ollila DW. The Role of Intraoperative Radiation in Early-stage Breast Cancer. Clin Breast Cancer 2021; 21:103-111. [PMID: 34030857 DOI: 10.1016/j.clbc.2020.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/01/2020] [Accepted: 12/21/2020] [Indexed: 11/17/2022]
Abstract
Intraoperative radiation therapy (IORT) is a specialized form of accelerated partial breast irradiation in which a single dose of radiation is delivered to the tumor bed at the time of breast conserving surgery. With completion of radiation to the tumor bed at the time of surgery, IORT promises improved patient convenience, compliance, and quality of life. In addition, with its potentially skin-sparing properties and ability to deliver a high biologically effective dose to the tumor bed while reducing dose to nontarget tissues, IORT results in different but overall less toxicities compared with other modalities of radiation for breast cancer. However, skepticism over the role of IORT in breast cancer exists, and the 2 randomized trials that have analyzed IORT as the definitive radiation component of breast conservation therapy have shown an increase in local recurrence rates with IORT compared with whole breast irradiation, but similar rates of overall survival. In this review, we discuss the practicalities of IORT, the prospective data supporting and negating the role of IORT in lieu of whole breast irradiation, and the toxicity after IORT in early-stage breast cancer. We also review the role of IORT as a radiation boost and specific strategies for successful implementation of IORT in breast cancer.
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Affiliation(s)
- Dana L Casey
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC.
| | - Gaorav P Gupta
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - David W Ollila
- Division of Surgical Oncology, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
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Dodelzon K, Starikov A, Reichman M, Cheng E, Lu CM, Blackburn A, Reznik E, Kim J, Bose A, Thomas C, Askin G, Arleo EK. Breast cancer in women under age 40: A decade of trend analysis at a single institution. Clin Imaging 2021; 78:165-70. [PMID: 33836424 DOI: 10.1016/j.clinimag.2021.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 03/17/2021] [Accepted: 03/21/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Women should be evaluated for breast cancer risk by age 30 to assess for screening need. Recent trends in breast cancer in this population may further inform recommendations. OBJECTIVE The aim of this study was to analyze trends over time in the rate of breast cancer, tumor characteristics and treatment in women under age 40. METHODS Retrospective cohort study of women under age 40 at our institution diagnosed with breast cancer from January 2007 to April 2018 was conducted. Patient demographics, tumor characteristics and treatment outcomes were collected. Descriptive statistics and the Mann-Kendell Trend test were calculated. Two-proportion z-tests were used to compare proportions of stage, pathology and treatment between 2007-2013 and 2014-2018. RESULTS 197 women under age 40 were treated for a new diagnosis of breast cancer at our institution. A higher proportion of women were diagnosed with invasive carcinoma in 2013-2018 (91%) compared to 2007-2012 (78%), p = 0.008. A higher proportion of women were diagnosed with advanced stage disease (stage III-IV) in 2013-2018 (24%) compared to 2007-2012 (2%), p = 0.001. No statistically significant evidence for an increasing trend of overall rate of breast cancer over the last 11 years (p = 0.419) was observed. CONCLUSIONS While no statistically significant increase in overall rate of breast cancer was noted, an increase in invasive and later staged breast cancers was observed. CLINICAL IMPACT Rise in more aggressive cancers in a population that is largely not screened may have implications both on the individual young woman's morbidity as well as on a public health level.
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Koopmansch C, Noël JC, Maris C, Simon P, Sy M, Catteau X. Intraoperative Evaluation of Resection Margins in Breast-Conserving Surgery for In Situ and Invasive Breast Carcinoma. Breast Cancer (Auckl) 2021; 15:1178223421993459. [PMID: 33854326 PMCID: PMC8013925 DOI: 10.1177/1178223421993459] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 01/15/2021] [Indexed: 11/16/2022]
Abstract
Background: The challenge of breast-conserving surgery (BCS) is to remove the entire tumour with free margins and avoid secondary excision that may adversely affect the cosmetic outcome. Consequently, intraoperative evaluation of surgical margins is critical. The aims of this study were multiple. First, to analyse our methodology of intraoperative examination of the resection margins and to evaluate radiological and pathological methods in the assessment of the surgical margins. Second, to evaluate the factors associated with positive margins in our patient population. M&m: The data on the resection margin status of 290 patients who underwent BCS for invasive carcinoma or ductal carcinoma in situ (DCIS) between 2009 and 2016 were reviewed. Results: In the cohort of BCS with invasive carcinoma, the negative predictive value was 97.4% for intraoperative assessment by radiography and 81.8% for intraoperative assessment by pathology. The re-operation rate among cases without intraoperative assessment was 23.6% compared to 7.3% among cases with intraoperative assessment (P = .003). Margin status was significantly associated with tumour size, histological subtype (invasive lobular carcinoma), and multifocality. In the population of BCS with DCIS, margin status was significantly associated with preoperative localisation and intraoperative margin assessment (P = .03). Conclusion: There is no statistical difference between pathological and radiological intraoperative assessment. Tumour size, lobular subtype, and multifocality were found to be significantly associated with positive margins in cases with invasive carcinoma, whereas absence of intraoperative margin assessment was significantly associated with positive margins in cases with DCIS. Therefore, intraoperative margin assessment improves the likelihood of complete excision of the lesion.
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Affiliation(s)
- Caroline Koopmansch
- Department of Pathology, Pathology and Genetic Institute, Gosselies, Belgium
| | - Jean-Christophe Noël
- Department of Pathology, Erasme University Hospital, Free University of Brussels (ULB), Brussels, Belgium
| | - Calliope Maris
- Department of Pathology, Erasme University Hospital, Free University of Brussels (ULB), Brussels, Belgium
| | - Philippe Simon
- Department of Gynaecology, Erasme University Hospital, Free University of Brussels (ULB), Brussels, Belgium
| | - Marième Sy
- Department of Radiology, Erasme University Hospital, Free University of Brussels (ULB), Brussels, Belgium
| | - Xavier Catteau
- Department of Pathology, CUREPATH laboratory (CHIREC, CHU Tivoli), Jumet, Belgium
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Garcia MT, Mota BS, Cardoso N, Martimbianco ALC, Ricci MD, Carvalho FM, Gonçalves R, Soares Junior JM, Filassi JR. Accuracy of frozen section in intraoperative margin assessment for breast-conserving surgery: A systematic review and meta-analysis. PLoS One 2021; 16:e0248768. [PMID: 33735315 PMCID: PMC7971883 DOI: 10.1371/journal.pone.0248768] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 03/04/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVES It is well established that tumor-free margin is an important factor for reducing local recurrence and reoperation rates. This systematic review with meta-analysis of frozen section intraoperative margin assessment aims to evaluate the accuracy, and reoperation and survival rates, and to establish its importance in breast-conserving surgery. METHODS A thorough review was conducted in all online publication-databases for the related literature up to March 2020. MeSH terms used: "Breast Cancer", "Segmental Mastectomy" and "Frozen Section". We included the studies that evaluated accuracy of frozen section, reoperation and survival rates. To ensure quality of the included articles, the QUADAS-2 tool (adapted) was employed. The assessment of publication bias by graphical and statistical methods was performed using the funnel plot and the Egger's test. The review protocol was registered in PROSPERO (CRD42019125682). RESULTS Nineteen studies were deemed suitable, with a total of 6,769 cases. The reoperation rate on average was 5.9%. Sensitivity was 0.81, with a Confidence Interval of 0.79-0.83, p = 0.0000, I2 = 95.1%, and specificity was 0.97, with a Confidence Interval of 0.97-0.98, p = 0.0000, I-2 = 90.8%, for 17 studies and 5,615 cases. Accuracy was 0.98. Twelve studies described local recurrence and the highest cumulative recurrence rate in 3 years was 7.5%. The quality of the included studies based on the QUADAS-2 tool showed a low risk of bias. There is no publication bias (p = 0.32) and the funnel plot showed symmetry. CONCLUSION Frozen section is a reliable procedure with high accuracy, sensitivity and specificity in intraoperative margin assessment of breast-conserving surgery. Therefore, this modality of margin assessment could be useful in reducing reoperation rates.
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Affiliation(s)
| | - Bruna Salani Mota
- Department of Gynaecology/Obstetrics, University of São Paulo, São Paulo, Brazil
| | | | | | | | | | - Rodrigo Gonçalves
- Department of Gynaecology/Obstetrics, University of São Paulo, São Paulo, Brazil
| | | | - José Roberto Filassi
- Department of Gynaecology/Obstetrics, University of São Paulo, São Paulo, Brazil
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Cartagena LC, McGuire K, Zot P, Pillappa R, Idowu M, Robila V. Breast-Conserving Surgeries With and Without Cavity Shave Margins Have Different Re-excision Rates and Associated Overall Cost: Institutional and Patient-Driven Decisions for Its Utilization. Clin Breast Cancer 2021; 21:e594-e601. [PMID: 33814286 DOI: 10.1016/j.clbc.2021.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/27/2021] [Accepted: 03/03/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Reducing the rate of margin positivity and reoperations remains a paramount goal in breast-conserving surgery (BCS). This study assesses the effectiveness of standard partial mastectomy with cavity shave margins (CSM) compared with partial mastectomy with selective margin resection (SPM), with regard to outcomes of the initial surgeries, re-excisions, and overall costs. PATIENTS AND METHODS This is a retrospective review of 122 eligible breast cancer patients who underwent BCS at one institution. The CSM and SPM groups each included 61 patients, matched for presurgical diagnoses and clinical stage. Data including margin status, rates and reason for re-excision, associated operation times, and costs were analyzed. RESULTS Patients undergoing CSM had less than half the rate of positive margins (PMs) (10% vs. 23%; P = .03) and re-excisions (8% vs. 23%; P = .02) compared with SPM. In the former group, the margin involvement was focal, and re-excisions were performed almost exclusively for PMs. For SPM, the majority (92%) of PMs were on the main lumpectomy specimen rather than the selective margins, and re-excisions included, in addition to PMs, extensive or multifocal negative but close margins. Reduced breast tissue volumes were removed with CSM, particularly for patients undergoing a single surgery (47 vs. 165 cm3; P < .001). The initial surgery with CSM is on average 27% more costly than that for SPM (P < .001), due to the increased pathology costs which are partially offset by the increased re-excision rates in SPM. CONCLUSION Circumferential cavity shaving, associated with consistent lower PMs, tissue volumes excised, and re-excision rates, is appropriate for routine implementation as a method offering superior surgical outcomes.
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Affiliation(s)
| | - Kandace McGuire
- Department of Surgery, Virginia Commonwealth University, Richmond, VA
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30
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Yang C, Lei C, Zhang Y, Zhang J, Ji F, Pan W, Zhang L, Gao H, Yang M, Li J, Wang K. Comparison of Overall Survival Between Invasive Lobular Breast Carcinoma and Invasive Ductal Breast Carcinoma: A Propensity Score Matching Study Based on SEER Database. Front Oncol 2020; 10:590643. [PMID: 33415073 PMCID: PMC7783385 DOI: 10.3389/fonc.2020.590643] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 11/13/2020] [Indexed: 11/22/2022] Open
Abstract
Objective Invasive lobular carcinoma (ILC) and invasive ductal carcinoma (IDC) account for most breast cancers. However, the overall survival (OS) differences between ILC and IDC remain controversial. This study aimed to compare nonmetastatic ILC to IDC in terms of survival and prognostic factors for ILC. Methods This retrospective cohort study used data from the Surveillance, Epidemiology and End Results (SEER) Cancer Database (www.seer.cancer.gov). Women diagnosed with nonmetastatic ILC and IDC between 2006 and 2016 were included. A propensity score matching (PSM) method was used in our analysis to reduce baseline differences in clinicopathological characteristics and survival outcomes. Kaplan-Meier curves and log-rank test were used for survival analysis. Results Compared to IDC patients, ILC patients were diagnosed later in life with poorly differentiated and larger lesions, as well as increased expression of estrogen receptors (ERs) and/or progesterone receptors (PRs). A lower rate of radiation therapy and chemotherapy was observed in ILC. After PSM, ILC, and IDC patients exhibited similar OS (HR=1.017, p=0.409, 95% CI: 0.967–1.069). In subgroup analysis of HR-negative, AJCC stage III, N2/N3 stage patients, or those who received radiotherapy, ILC patients exhibited worse OS compared to IDC patients. Furthermore, multivariate analysis revealed a 47% survival benefit for IDC compared to ILC in HR-negative patients who received chemotherapy (HR=1.47, p=0.01, 95% CI: 1.09–1.97). Conclusions Our results demonstrated that ILC and IDC patients had similar OS after PSM. However, ILC patients with high risk indicators had worse OS compared to IDC patients by subgroup analysis.
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Affiliation(s)
- Ciqiu Yang
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Chuqian Lei
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,Department of Breast and Thyroid Surgery, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Yi Zhang
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Junsheng Zhang
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Fei Ji
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Weijun Pan
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Liulu Zhang
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Hongfei Gao
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Mei Yang
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jieqing Li
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Kun Wang
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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Tamirisa N, Lei X, Caudle AS, Giordano SH, Zhao H, Chavez-MacGregor M. Impact of SSO-ASTRO "No Ink on Tumor" Guidelines on Reexcision Rates among Older Breast Cancer Patients. Ann Surg Oncol 2020; 28:3703-3713. [PMID: 33225394 DOI: 10.1245/s10434-020-09370-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 10/26/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND The SSO-ASTRO consensus guideline on invasive breast cancer defined negative margin as no ink on tumor, obviating the need for reexcision in some patients. We evaluated the impact of these recommendations on the rates of reexcision in older breast cancer patients undergoing breast-conserving surgery (BCS). PATIENTS AND METHODS Women age ≥ 66 years with stage I-II breast cancer who underwent BCS and radiation were identified in the SEER-Medicare linked database (2012-2015). We divided patients into three cohorts: pre-guideline (January 2012 to September 2013), peri-guideline (October 2013 to March 2014), and post-guideline (April 2014 to September 2016). Descriptive statistics were used, and the relative change in reexcision rate between the pre- and post-guideline periods was calculated. Multivariable logistic regression was used to evaluate factors associated with risk of reexcision. RESULTS A total of 11,639 patients were included (pre-guideline, N = 5211; peri-guideline, N = 1366; post-guideline, N = 5062); overall, 21.7% of patients underwent reexcision. The reexcision rates decreased after the guideline was published (23.5% vs. 19.3%, p < 0.001). In the multivariable model, BCS during the post-guideline period was associated with a statistically significant decreased risk of reexcision (RR = 0.84; 95% CI 0.78-0.90). Lobular histology was associated with a higher risk of reexcision (RR = 1.32; 95% CI 1.19-1.46), and greater surgeon volume was associated with lower risk of reexcision (RR = 0.92; 95% CI 0.85-1.0). CONCLUSIONS Among older breast cancer patients undergoing BCS for invasive cancer, reexcision rates decreased with the dissemination of the SSO-ASTRO consensus guideline. Identifying factors associated with higher rates of reexcision could improve guideline compliance and reduce the frequency of unnecessary interventions in older patients.
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Affiliation(s)
- Nina Tamirisa
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xiudong Lei
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Abigail S Caudle
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sharon H Giordano
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hui Zhao
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mariana Chavez-MacGregor
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA. .,Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Kaufman CS, Cross MJ, Barone JL, Dekhne NS, Devisetty K, Dilworth JT, Edmonson DA, Eladoumikdachi FG, Gass JS, Hall WH, Hong RL, Kuske RR, Patton BJ, Perelson C, Phillips RF, Smith AB, Smith LA, Tafra L, Lebovic GS. A Three-Dimensional Bioabsorbable Tissue Marker for Volume Replacement and Radiation Planning: A Multicenter Study of Surgical and Patient-Reported Outcomes for 818 Patients with Breast Cancer. Ann Surg Oncol 2020; 28:2529-2542. [PMID: 33221977 PMCID: PMC8043870 DOI: 10.1245/s10434-020-09271-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 10/05/2020] [Indexed: 12/14/2022]
Abstract
Background Accurate identification of the tumor bed after breast-conserving surgery (BCS) ensures appropriate radiation to the tumor bed while minimizing normal tissue exposure. The BioZorb® three-dimensional (3D) bioabsorbable tissue marker provides a reliable target for radiation therapy (RT) planning and follow-up evaluation while serving as a scaffold to maintain breast contour. Methods After informed consent, 818 patients (826 breasts) implanted with the BioZorb® at 14 U.S. sites were enrolled in a national registry. All the patients were prospectively followed with the BioZorb® implant after BCS. The data collected at 3, 6, 12, and 24 months included all demographics, treatment parameters, and provider/patient-assessed cosmesis. Results The median follow-up period was 18.2 months (range, 0.2–53.4 months). The 30-day breast infection rate was 0.5 % of the patients (n = 4), and re-excision was performed for 8.1 % of the patients (n = 66), whereas 2.6 % of the patients (n = 21) underwent mastectomy. Two patients (0.2 %) had local recurrence. The patient-reported cosmetic outcomes at 6, 12, and 24 months were rated as good-to-excellent by 92.4 %, 90.6 %, and 87.3 % of the patients, respectively and similarly by the surgeons. The radiation oncologists reported planning of target volume (PTV) reduction for 46.2 % of the patients receiving radiation boost, with PTV reduction most commonly estimated at 30 %. Conclusions This report describes the first large multicenter study of 818 patients implanted with the BioZorb® tissue marker during BCS. Radiation oncologists found that the device yielded reduced PTVs and that both the patients and the surgeons reported good-to-excellent long-term cosmetic outcomes, with low adverse effects. The BioZorb® 3D tissue marker is a safe adjunct to BCS and may add benefits for both surgeons and radiation oncologists. Electronic supplementary material The online version of this article (10.1245/s10434-020-09271-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Cary S Kaufman
- Department of Surgery, University of Washington, Seattle, WA, USA. .,Bellingham Regional Breast Center, 2075 Barkley Blvd. Suite 250, Bellingham, WA, USA.
| | | | | | | | | | | | - David A Edmonson
- Womens Oncology, Women and Infants Hospital, Providence, RI, USA
| | | | - Jennifer S Gass
- Women and Infants Hospital, Breast Health Center, Providence, RI, USA
| | - William H Hall
- Radiation Oncology, PeaceHealth St. Joseph Medical Center, Bellingham, WA, USA
| | - Robert L Hong
- Virginia Hospital Center, Arlington Health System, Arlington, VA, USA
| | | | | | | | | | | | | | - Lorraine Tafra
- Anne Arundel Medical Center, The Breast Center, Annapolis, MD, USA
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Lu T, Jorns JM, Patton M, Fisher R, Emmrich A, Doehring T, Schmidt TG, Ye DH, Yen T, Yu B. Rapid assessment of breast tumor margins using deep ultraviolet fluorescence scanning microscopy. J Biomed Opt 2020; 25:JBO-200272R. [PMID: 33241673 PMCID: PMC7688317 DOI: 10.1117/1.jbo.25.12.126501] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 10/28/2020] [Indexed: 06/02/2023]
Abstract
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.
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Affiliation(s)
- Tongtong Lu
- Marquette University and Medical College of Wisconsin, Department of Biomedical Engineering, Milwaukee, Wisconsin, United States
| | - Julie M. Jorns
- Medical College of Wisconsin, Department of Pathology, Milwaukee, Wisconsin, United States
| | - Mollie Patton
- Medical College of Wisconsin, Department of Pathology, Milwaukee, Wisconsin, United States
| | - Renee Fisher
- Marquette University and Medical College of Wisconsin, Department of Biomedical Engineering, Milwaukee, Wisconsin, United States
| | - Amanda Emmrich
- Medical College of Wisconsin, Department of Surgery, Milwaukee, Wisconsin, United States
| | | | - Taly Gilat Schmidt
- Marquette University and Medical College of Wisconsin, Department of Biomedical Engineering, Milwaukee, Wisconsin, United States
| | - Dong Hye Ye
- Marquette University, Department of Electrical and Computer Engineering, Milwaukee, Wisconsin, United States
| | - Tina Yen
- Medical College of Wisconsin, Department of Surgery, Milwaukee, Wisconsin, United States
| | - Bing Yu
- Marquette University and Medical College of Wisconsin, Department of Biomedical Engineering, Milwaukee, Wisconsin, United States
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Marinovich ML, Noguchi N, Morrow M, Houssami N. Changes in Reoperation After Publication of Consensus Guidelines on Margins for Breast-Conserving Surgery: A Systematic Review and Meta-analysis. JAMA Surg 2020; 155:e203025. [PMID: 32857107 DOI: 10.1001/jamasurg.2020.3025] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance The 2014 publication of the Society of Surgical Oncology-American Society for Radiation Oncology (SSO-ASTRO) Consensus Guideline on Margins for Breast-Conserving Surgery recommended a negative margin definition of no ink on tumor. Adoption of this guideline would represent a major change in surgical practice that could lower the rates of reoperation. Objective To assess changes in reoperation rates after publication of the SSO-ASTRO guideline. Data Sources A systematic search of Embase, PREMEDLINE, Evidence-Based Medicine Reviews, Scopus, and Web of Science for biomedical literature published from January 2014 to July 2019 was performed. This search was supplemented by web searches and manual searching of conference abstracts. Study Selection Included studies compared the reoperation rates in preguideline vs postguideline cohorts (actual change), retrospectively applied the SSO-ASTRO guideline to a preguideline cohort (projected change), or described the economic outcomes of the guideline. Data Extraction and Synthesis Study characteristics and reoperation rates were extracted independently by 2 reviewers. Odds ratios (ORs) were pooled by random effects meta-analysis. Analyses were stratified by study setting (institutional or population) and preguideline accepted margins. The economic outcomes of the guideline were summarized narratively. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was followed. Main Outcomes and Measures Odds ratios for postguideline vs preguideline reoperation rates. Results From 1114 citations, 30 studies (with 599 016 participants) reported changes in reoperation rates. Studies included a median (range) of 487 (100-521 578) participants, and 20 studies were undertaken in the US, 6 in the UK, 3 in Canada, and 1 in Australia. Among 21 studies of actual changes, pooled ORs showed a statistically significant reduction in reoperation, with an OR lower in institution-based studies than in population-based studies (OR, 0.62 [95% CI, 0.52-0.74] vs 0.76 [95% CI, 0.72-0.80]; P = .04 for subgroup differences). Among 9 studies of projected changes, the pooled OR was lower for preguideline margin thresholds of 2 mm or more compared with 1 mm (OR, 0.47 [95% CI, 0.40-0.56] vs 0.85 [95% CI, 0.79-0.91; P < .001 for subgroup differences). Projected changes were likely to overestimate actual changes. Six studies that estimated the postguideline economic outcome found the guideline to be potentially cost saving, with a median (range) saving of US $3540 ($1800-$25 650) per woman avoiding reoperation. Conclusions and Relevance This study found a decrease in reoperation rates after the publication of the SSO-ASTRO guideline; this reduction was greater at an institutional level than a population level, the latter reflecting the differences in guideline adoption between centers. These early outcomes may be conservative estimates of longer-term implications.
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Affiliation(s)
- M Luke Marinovich
- School of Public Health, Curtin University, Bentley, Western Australia, Australia.,Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Naomi Noguchi
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Monica Morrow
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Nehmat Houssami
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Affiliation(s)
- Yiming Gao
- From the Department of Radiology, New York University School of Medicine, 160 E 34th St, New York, NY 10016
| | - Samantha L. Heller
- From the Department of Radiology, New York University School of Medicine, 160 E 34th St, New York, NY 10016
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Widen JC, Tholen M, Yim JJ, Antaris A, Casey KM, Rogalla S, Klaassen A, Sorger J, Bogyo M. AND-gate contrast agents for enhanced fluorescence-guided surgery. Nat Biomed Eng 2021; 5:264-77. [PMID: 32989286 DOI: 10.1038/s41551-020-00616-6] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 08/27/2020] [Indexed: 12/18/2022]
Abstract
The surgical resection of tumours requires the precise location and definition of the margins between lesions and normal tissue. However, this is made difficult by irregular margin borders. Although molecularly targeted optical contrast agents can be used to define tumour margins during surgery in real time, the selectivity of the contrast agents is often limited by the target being expressed in both healthy and tumour tissues. Here, we show that AND-gate optical imaging probes requiring the processing of two substrates by multiple tumour-specific enzymes produce a fluorescent signal with significantly improved specificity and sensitivity to tumour tissue. We evaluated the performance of the probes in mouse models of mammary tumours and of metastatic lung cancer, and during fluorescence-guided robotic surgery. Imaging probes relying on multivariate activation to selectively target complex patterns of enzymatic activity should be useful in disease detection, treatment and monitoring.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Abstract
Importance Overtreatment of early-stage breast cancer results in increased morbidity and cost without improving survival. Major surgical organizations participating in the Choosing Wisely campaign identified 4 breast cancer operations as low value: (1) axillary lymph node dissection for limited nodal disease in patients receiving lumpectomy and radiation, (2) re-excision for close but negative lumpectomy margins for invasive cancer, (3) contralateral prophylactic mastectomy in patients at average risk with unilateral cancer, and (4) sentinel lymph node biopsy in women 70 years or older with hormone receptor-positive cancer. Objective To evaluate the extent to which these procedures have been deimplemented, determine the implications of decreased use, and recognize possible barriers and facilitators to deimplementation. Evidence Review A systematic review of published literature on use trends in breast surgery was performed in accordance with PRISMA guidelines. The Ovid, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases were searched for original research with relevance to the Choosing Wisely recommendations of interest. Eligible studies were examined for data about use, and any patient-level, clinician-level, or system-level factors associated with use. Findings Concordant with recommendations, national rates of axillary lymph node dissection for patients with limited nodal disease have decreased by approximately 50% (from 44% in 2011 to 30% to 34% in 2012 and 25% to 28% in 2013), and national rates of lumpectomy margin re-excision have decreased by nearly 40% (from 16% to 34% before to 14% to 18% after publication of a consensus statement). Conversely, national rates of contralateral prophylactic mastectomy continue to rise each year, accounting for up to 30% of all mastectomies for breast cancer (range in all mastectomy cases: 2010-2012, 28%-30%; 1998, <2%), and rates of sentinel lymph node biopsy in women 70 years or older with low-risk breast cancer are persistently greater than 80% (range, 80%-88%). Factors associated with high rates of contralateral prophylactic mastectomy use are younger age, white race, increased socioeconomic status, and the availability of breast reconstruction; limited data exist on factors associated with high rates of sentinel lymph node biopsy in women 70 years or older. Successful deimplementation of axillary lymph node dissection and lumpectomy margin re-excision were associated with decreased costs and improved patient-centered outcomes. Conclusions and Relevance This review demonstrates variable deimplementation of 4 low-value surgical procedures in patients with breast cancer. Addressing specific patient-level, clinician-level, and system-level barriers to deimplementation is necessary to encourage shared decision-making and reduce overtreatment.
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Affiliation(s)
- Ton Wang
- Department of Surgery, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | | | - Lesly A. Dossett
- Department of Surgery, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
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Partain N, Calvo C, Mokdad A, Colton A, Pouns K, Clifford E, Farr D, Huth J, Wooldridge R, Leitch AM. Differences in Re-excision Rates for Breast-Conserving Surgery Using Intraoperative 2D Versus 3D Tomosynthesis Specimen Radiograph. Ann Surg Oncol 2020; 27:4767-4776. [PMID: 32740738 DOI: 10.1245/s10434-020-08877-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 06/19/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Intraoperative specimen radiographs performed during breast conservation surgery for cancer reduces the need for re-excision for positive margins. We studied 2D versus 3D image-guided cavity margin excision and compared it to final pathology and need for additional surgery. METHODS We conducted a retrospective review of 657 breast-conserving operations performed for cancer from 2013 to 2018. Procedures were performed by four surgeons at a single tertiary institution with access intraoperatively to 2D and 3D radiographs. Data collected included demographics, intraoperative margin assessment, final pathology, and re-excision rates. RESULTS A total of 466 patients had 2D and 191 had 3D specimen imaging. The 2D group had a lower mean age and a higher body mass index and proportion of minority patients than the 3D group (P < 0.01). In the 3D group, there was a higher percentage of patients with mammographically denser breasts (P < 0.06); 58% of patients in the 3D group had additional imaging-directed cavity margins excised versus 32% of patients in the 2D group (P < 0.01). In the 2D group, 44 patients (9%) had positive final margins versus 8 patients (4%) in the 3D group (P = 0.02). No difference was found on total volume of excision (P = 0.56). The re-excision rate for the 2D group was 11% versus 5% for the 3D group (P = 0.02; adjusted odds ratio = 0.41, 95% confidence interval 0.19-0.86). CONCLUSIONS Re-excision rates using both modalities are low. A lower re-excision rate is independently associated with 3D tomosynthesis. This allows surgeons to excise additional margins at the index operation, decreasing reoperations and anxiety/costs for patients.
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Affiliation(s)
- Natalia Partain
- Division of Surgical Oncology, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Carissia Calvo
- Division of Surgical Oncology, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ali Mokdad
- Division of Surgical Oncology, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Andrea Colton
- Division of Surgical Oncology, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Katherine Pouns
- Division of Surgical Oncology, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Edward Clifford
- Division of Surgical Oncology, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Deborah Farr
- Division of Surgical Oncology, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - James Huth
- Division of Surgical Oncology, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rachel Wooldridge
- Division of Surgical Oncology, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - A Marilyn Leitch
- Division of Surgical Oncology, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
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Shah C, Hobbs BP, Vicini F, Al-Hilli Z, Manyam BV, Verma V, Jia X, Goldstein N, Recht A. The Diminishing Impact of Margin Definitions and Width on Local Recurrence Rates following Breast-Conserving Therapy for Early-Stage Invasive Cancer: A Meta-Analysis. Ann Surg Oncol 2020; 27:4628-4636. [PMID: 32712894 DOI: 10.1245/s10434-020-08878-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 01/29/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND The optimal tumor-free margin definition and width following breast-conserving therapy (BCT) for early-stage invasive cancers has been evaluated in previous meta-analyses and guidelines. We performed an updated meta-analysis to assess how improvements in treatment over time have affected the impact of margins on local recurrence (LR) rates over time. METHODS A systematic literature review identified 38 eligible studies comprising 54,502 patients treated between 1968 and 2010. Inclusion criteria included patients treated with BCT and minimum follow-up of 50 months, pathologic definitions of margin status explicitly stated, and LR data in relation to margin status. Data were pooled using a Bayesian logistic regression model to evaluate the risk of LR in relation to both margin status and study enrollment periods. RESULTS Median follow-up was 7.25 years. Absolute LR rates decreased over time for each margin width cohort, with maximum differences between negative margin groups of less than 1% for the most recent enrollment period. However, relative rates of LR between different margin groups remained stable over time. CONCLUSIONS With an additional 22,000 patients compared with the previous meta-analysis, this updated meta-analysis supports the consensus guideline of "no tumor on ink" for the majority of patients. Additionally, while concerns exist regarding a benefit with wider margins from previous studies, the analysis demonstrates the impact of margin width on LR rates has declined substantially over time, with very small differences between the narrowest and widest margin groups in the most recent cohort. Hence, older studies appear to have limited value to inform current management guidelines.
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Affiliation(s)
- Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Brian P Hobbs
- Quantitative Health Sciences, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Frank Vicini
- 21st Century Oncology, Michigan Healthcare Professionals, Farmington Hills, MI, USA
| | - Zahraa Al-Hilli
- Department of Breast Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Bindu V Manyam
- Department of Radiation Oncology, Alleghany Health Network, Pittsburgh, PA, USA
| | - Vivek Verma
- Department of Radiation Oncology, Alleghany Health Network, Pittsburgh, PA, USA
| | - Xuefei Jia
- Quantitative Health Sciences, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Abram Recht
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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LeeVan E, Ho BT, Seto S, Shen J. Use of MarginProbe as an adjunct to standard operating procedure does not significantly reduce re-excision rates in breast conserving surgery. Breast Cancer Res Treat 2020; 183:145-151. [PMID: 32607640 DOI: 10.1007/s10549-020-05773-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 06/23/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE A positive margin after breast conserving surgery has consistently been shown to be a significant predictor for ipsilateral breast tumor recurrence. Currently, there is no standard for intraoperative margin assessment during lumpectomy, and up to 20% of cases result in positive margins. MarginProbe is a device that provides real-time evaluation of lumpectomy margins during surgery. The aim of this study was to evaluate the impact of MarginProbe as an adjunct to standard operating procedure (SOP). METHODS Patients diagnosed with breast cancer scheduled for breast conserving surgery were consented for intraoperative use of MarginProbe. Shaved margins were excised based on margin assessment using the surgeon's SOP which included specimen radiography and gross pathologic examination, and feedback from the device. The primary endpoint was re-excision rate. Secondary endpoints included sensitivity, specificity, false-positive and negative rates. RESULTS Of the 60 breast cancers, initial histologically close/positive margins were identified in 18 patients (30%). The re-excision rate in the overall cohort was 6.6%, compared to a historical re-excision rate of 8.6% (p < 0.01). Based on 360 measurement sites, MarginProbe demonstrated a sensitivity of 67% and specificity of 60%, with a positive predictive value of 16%, and of negative predictive value of 94%, which was similar to the accuracy of SOP. CONCLUSIONS MarginProbe performs equally as well as specimen radiography and gross pathologic examination. In this setting where the baseline re-excision rate was low, the use of MarginProbe as an adjunct to SOP resulted in a small 2% absolute reduction in re-excision rate.
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Affiliation(s)
- Elyse LeeVan
- Department of Surgery, Huntington Hospital, 100 W California Blvd, Pasadena, CA, 91105, USA
| | - Be Thi Ho
- Department of Surgery, Huntington Hospital, 100 W California Blvd, Pasadena, CA, 91105, USA
| | - Sadie Seto
- Department of Clinical Research, Huntington Hospital, 100 W California Blvd, Pasadena, CA, 91105, USA
| | - Jeannie Shen
- Department of Surgery, Huntington Hospital, 100 W California Blvd, Pasadena, CA, 91105, USA. .,Department of Surgery, University of California Los Angeles, 10833 Le Conte Ave #72, Los Angeles, CA, 90024, USA. .,, 625 S Fair Oaks Ave, Suite 300, Pasadena, CA, 91105, USA.
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Abstract
Breast cancer is the most frequent cancer in women all over the world. The prognosis is generally good, with a five-year overall survival rate above 90% for all stages. It is still the second leading cause of cancer-related death among women. Surgical treatment of breast cancer has changed dramatically over the years. Initially, treatment involved major surgery with long hospitalization, but it is now mostly accomplished as an outpatient procedure with a quick recovery. Thanks to well-designed retrospective and randomly controlled prospective studies, guidelines are continually changing. We are presently in an era where safely de-escalating surgery is increasingly emphasized. Breast cancer is a heterogenous disease, where a "one-size-fits-all" treatment approach is not appropriate. There is often more than one surgical solution carrying equal oncological safety for an individual patient. In these situations, it is important to include the patient in the treatment decision-making process through well informed consent. For this to be optimal, the physician must be fully updated on the surgical options. A consequence of an improved prognosis is more breast cancer survivors, and therefore physical appearance and quality of life is more in focus. Modern breast cancer treatment is increasingly personalized from a surgical point of view but is dependent on a multidisciplinary approach. Detailed algorithms for surgery of the breast and the axilla are required for optimal treatment and quality control. This review illustrates how breast cancer treatment has changed over the years and how the current standard is based on high quality scientific research.
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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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Mamtani A, Romanoff A, Baser R, Vincent A, Morrow M, Gemignani ML. Adoption of SSO-ASTRO Margin Guidelines for Ductal Carcinoma in Situ: What Is the Impact on Use of Additional Surgery? Ann Surg Oncol 2020; 28:295-302. [PMID: 32500343 DOI: 10.1245/s10434-020-08610-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Historically, more than one-third of patients with ductal carcinoma in situ (DCIS) treated with breast-conserving surgery (BCS) underwent additional surgery. The SSO-ASTRO guidelines advise 2 mm margins for patients with DCIS having BCS and whole-breast radiation (WBRT). Here we examine guideline impact on additional surgery and factors associated with re-excision. PATIENTS AND METHODS Patients treated with BCS for pure DCIS from August 2015 to January 2018 were identified. Guidelines were adopted on September 1, 2016, and all patients had separately submitted cavity-shave margins. Clinicopathologic characteristics, margin status, and rates of additional surgery were examined. RESULTS Among 650 patients with DCIS who attempted BCS, 50 (8%) converted to mastectomy. Of 600 who had BCS as final surgery, 336 (56%) received WBRT and comprised our study group. One hundred twenty-eight (38%) were treated pre-guideline and 208 (62%) were treated post-guideline. Characteristics and margin status were similar between groups. The re-excision rate was 38% pre-guideline adoption and 29% post-guideline adoption (p = 0.09), with 91% having only one re-excision. Re-excision for ≥ 2 mm margins was uncommon (6% pre-guideline vs. 5% post-guideline). On multivariate analysis, younger age (OR 0.97, 95% CI 0.94-0.99, p = 0.02) and larger DCIS size (OR 1.43, 95% CI 1.2-1.8, p < 0.001) were predictive of re-excision; guideline era was not. Younger age (OR 0.93, 95% CI 0.9-0.97, p < 0.001) and larger size (OR 1.64, 95% CI 1.3-2.1, p < 0.001) were predictive of conversion to mastectomy, but residual tumor burden was low. CONCLUSIONS The SSO-ASTRO guidelines did not significantly change re-excision rates for DCIS in our practice, likely since re-excision for margins ≥ 2 mm was uncommon even prior to guideline adoption, dissimilar to historically observed variations in surgeon practices. Younger age and larger DCIS size were associated with additional surgery.
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Affiliation(s)
- Anita Mamtani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Anya Romanoff
- Breast Surgery, Dubin Breast Center, Icahn School of Medicine at The Mount Sinai Hospital, New York, NY, USA
| | - Raymond Baser
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alain Vincent
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mary L Gemignani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Kuritzky A, Reyna C, McGuire KP, Sun W, DeSnyder SM, Aubry S, Nayyar A, Strassle P, Hunt KK, Zhou JM, Lee MC. Evaluation of 2014 margin guidelines on re-excision and recurrence rates after breast conserving surgery: A multi-institution retrospective study. Breast 2020; 51:29-33. [PMID: 32199230 PMCID: PMC7375557 DOI: 10.1016/j.breast.2020.02.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 02/20/2020] [Accepted: 02/29/2020] [Indexed: 11/18/2022] Open
Abstract
Introduction A 2014 consensus statement from the Society of Surgical Oncology and American Society for Radiation Oncology supported “no ink on tumor” as an adequate margin for breast conserving therapy (BCT). This study evaluates this statement in a multi-institution cohort. Methods A retrospective review of BCT cases at 3 comprehensive cancer centers was performed. Women age >18 receiving BCT for T1-2 breast cancer from 2008-2012 were included. Pre-2014, all sites considered 2 mm adequate. Estimated re-excision rates using the 2014 guidelines were calculated and factors predictive of re-excision were analyzed. Results 542 patients (545 lumpectomies) were eligible. Using a ≥2 mm margin standard, 32.8% of patients underwent re-excision compared to 14.1% after 2014 (p < 0.0001). Tumor size (p= 0.003), grade (p=0.015), and lymphovascular invasion (p=0.021) were predictive of re-excision. Patients with additional intraoperative margins excised were less likely to require reoperation (p=0.002). Local recurrence was unaffected by re-excision after mean followup of 66 months. Conclusions The 2014 margin guidelines markedly reduce re-excision rates. There is no difference in local recurrence for patients after re-excision for a close margin versus without Powered. Multi-institution review 2014 consensus statement on margins for invasive breast cancer. Pooled results demonstrated a 32.8% re-excision rate reduced to 14.1% if the "no tumor on ink" guidelines were applied. No difference in local recurrence rates, including patients with close margins, after median followup of 67 months.
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Affiliation(s)
- Anne Kuritzky
- Comprehensive Breast Program, Moffitt Cancer Center Tampa, FL, USA
| | - Chantal Reyna
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Weihong Sun
- Comprehensive Breast Program, Moffitt Cancer Center Tampa, FL, USA
| | - Sara M DeSnyder
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Staci Aubry
- University of North Carolina Chapel Hill, NC, USA
| | | | | | - Kelly K Hunt
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jun-Min Zhou
- Department of Biostatistics, Moffitt Cancer Center Tampa, FL, USA
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Smith ME, Vitous CA, Hughes TM, Shubeck SP, Jagsi R, Dossett LA. Barriers and Facilitators to De-Implementation of the Choosing Wisely ® Guidelines for Low-Value Breast Cancer Surgery. Ann Surg Oncol 2020; 27:2653-2663. [PMID: 32124126 DOI: 10.1245/s10434-020-08285-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND To address overuse of unnecessary practices, several surgical organizations have participated in the Choosing Wisely® campaign and identified four breast cancer surgical procedures as unnecessary. Despite evidence demonstrating no survival benefit for all four, evidence suggests only two have been substantially de-implemented. Our objective was to understand why surgeons stop performing certain unnecessary cancer operations but not others and how best to de-implement entrenched and emerging unnecessary procedures. METHODS We sampled surgeons who treat breast cancer in a variety of practice types and geographic regions in the United States. Using a semi-structured guide, we conducted telephone interviews (n = 18) to elicit attitudes and understand practices relating to the four identified breast cancer procedures in the Choosing Wisely® campaign. Interviews were recorded, transcribed, and anonymized. Transcripts were analyzed using inductive and deductive thematic analysis. RESULTS For the two procedures successfully de-implemented, surgeons described a high level of confidence in the data supporting the recommendations. In contrast, surgeons frequently described a lack of familiarity or skepticism toward the recommendation to avoid sentinel-node biopsy in women ≥ 70 years of age and the influence of other collaborating oncology providers as justification for continued use. Regarding contralateral prophylactic mastectomy, surgeons consistently agreed with the recommendation that this was unnecessary, yet reported continued utilization due to the value placed on patient autonomy and preference. CONCLUSIONS With a growing focus on the elimination of ineffective, unproven or low value practices, it is imperative that the behavioral determinants are understood and targeted with specific interventions to decrease utilization rapidly.
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Affiliation(s)
- Margaret E Smith
- Department of Surgery, Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - C Ann Vitous
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Tasha M Hughes
- Department of Surgery, Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Sarah P Shubeck
- Department of Surgery, Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Lesly A Dossett
- Department of Surgery, Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA. .,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.
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Mariscotti G, Durando M, Pavan LJ, Tagliafico A, Campanino PP, Castellano I, Bussone R, Ala A, De Sanctis C, Bergamasco L, Fonio P, Houssami N. Intraoperative breast specimen assessment in breast conserving surgery: comparison between standard mammography imaging and a remote radiological system. Br J Radiol 2020; 93:20190785. [PMID: 32101449 DOI: 10.1259/bjr.20190785] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To compare standard specimen mammography (SSM) with remote intraoperative specimen mammography (ISM) assessment in breast conserving-surgery (BCS) based on operative times, intraoperative additional excision (IAE) and re-intervention rates. METHODS AND MATERIALS We retrospectively compared 129 consecutive patients (136 lesions) who had BCS with SSM at our centre between 11/2011 and 02/2013 with 138 consecutive patients (144 lesions) who underwent BCS with ISM between 08/2014 and 02/2015.SSM or ISM were performed to confirm the target lesions within the excised specimen and margin adequacy. The utility of SMM and ISM was evaluated considering pathology as gold-standard, using χ2 or Fisher's exact tests for comparison of categorical variables, and non-parametric Mann-Whitney test for continuous variables. RESULTS The two groups did not statistically differ for age (p = 0.20), lesion size (p = 0.29) and morphology (p = 0.82) or tumor histology type (p = 0.65). Intraoperative time was significantly longer (p < 0.00001) for SSM (132 ± 43 min) than for ISM (90 ± 42 min). The proportions requiring IAE did not significantly differ between SSM group (39/136 lesions (40%)) and ISM group (52/144 lesions (57%)) (p = 0.19), overall and in stratified analysis by mammographic features. Re-intervention rates were not statistically different between the two groups [SSM:19/136 (14%), ISM:13/144 (9%); p = 0.27]. CONCLUSION The introduction of ISM in BCS significantly reduced surgical time but did not change IAE and re-intervention rates, highlighting facilitated communication between surgeons and radiologists. ADVANCES IN KNOWLEDGE Compared to standard mammography imaging, the use of ISM significantly reduced surgical time.
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Affiliation(s)
- Giovanna Mariscotti
- Department of Diagnostic Imaging and Radiotherapy, Radiology Institute, University of Turin, A. O. U. Città della Salute e della Scienza di Torino, Presidio Ospedaliero Molinette Via Genova 3, 10126 Torino, Italy
| | - Manuela Durando
- Department of Diagnostic Imaging and Radiotherapy, Radiology Institute, University of Turin, A. O. U. Città della Salute e della Scienza di Torino, Presidio Ospedaliero Molinette Via Genova 3, 10126 Torino, Italy
| | - Luca Jacopo Pavan
- Department of Diagnostic Imaging and Radiotherapy, Radiology Institute, University of Turin, A. O. U. Città della Salute e della Scienza di Torino, Presidio Ospedaliero Molinette Via Genova 3, 10126 Torino, Italy
| | - Alberto Tagliafico
- Department of Experimental Medicine, University of Genoa IRCCS AOU San Martino - IST Istituto Nazionale per la Ricerca sul Cancro, 16132 Genoa, Italy
| | - Pier Paolo Campanino
- Breast Imaging Service. Ospedale Koelliker.C.so Galileo Ferraris 256 - 10100, Torino, Italy
| | - Isabella Castellano
- Department of Medical Sciences, University of Turin, A. O. U. Città della Salute e della Scienza di Torino, Presidio Ospedaliero Molinette, Via Santena, 7, Torino, Italy
| | - Riccardo Bussone
- Breast Surgery, Presidio Sanitario Ospedale Cottolengo Via S. Giuseppe Benedetto Cottolengo, 9 - 10152, Torino, Italy
| | - Ada Ala
- Breast Surgery, Department of Surgery, A. O. U. Città della Salute e della Scienza di Torino, Presidio Ospedaliero S. Anna, Via Ventimiglia, 1, 10126, Torino, Italy
| | - Corrado De Sanctis
- Department of Gynecology and Obstetrics, Breast Unit, A.O.U. Città della Salute e della Scienza di Torino, Presidio Ospedaliero S. Anna, Via Ventimiglia, 1, 10126 Torino, Italy
| | - Laura Bergamasco
- Department of Surgical Sciences, University of Torino, A. O. U. Città della Salute e della Scienza di Torino, Presidio Ospedaliero Molinette, C.so Bramante 88, 10126 Torino, Italy
| | - Paolo Fonio
- Department of Diagnostic Imaging and Radiotherapy, Radiology Institute, University of Turin, A. O. U. Città della Salute e della Scienza di Torino, Presidio Ospedaliero Molinette Via Genova 3, 10126 Torino, Italy
| | - Nehmat Houssami
- Screening and Test Evaluation Program, School of Public Health, Sydney Medical School, University of Sydney, Sydney, 2006, NSW, Australia
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DiCorpo D, Tiwari A, Tang R, Griffin M, Aftreth O, Bautista P, Hughes K, Gershenfeld N, Michaelson J. The role of Micro-CT in imaging breast cancer specimens. Breast Cancer Res Treat 2020; 180:343-357. [PMID: 32020431 DOI: 10.1007/s10549-020-05547-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 01/22/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE The goal of breast cancer surgery is to remove all of the cancer with a minimum of normal tissue, but absence of full 3-dimensional information on the specimen makes this difficult to achieve. METHOD Micro-CT is a high resolution, X-ray, 3D imaging method, widely used in industry but rarely in medicine. RESULTS We imaged and analyzed 173 partial mastectomies (129 ductal carcinomas, 14 lobular carcinomas, 28 DCIS). Imaging was simple and rapid. The size and shape of the cancers seen on Micro-CT closely matched the size and shape of the cancers seen at specimen dissection. Micro-CT images of multicentric/multifocal cancers revealed multiple non-contiguous masses. Micro-CT revealed cancer touching the specimen edge for 93% of the 114 cases judged margin positive by the pathologist, and 28 of the cases not seen as margin positive on pathological analysis; cancer occupied 1.55% of surface area when both the pathologist and Micro-CT suggested cancer at the edge, but only 0.45% of surface area for the "Micro-CT-Only-Positive Cases". Thus, Micro-CT detects cancers that touch a very small region of the specimen surface, which is likely to be missed on sectioning. CONCLUSIONS Micro-CT provides full 3D images of breast cancer specimens, allowing one to identify, in minutes rather than hours, while the patient is in OR, margin-positive cancers together with information on where the cancer touches the edge, in a fashion more accurate than possible from the histology slides alone.
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Affiliation(s)
- Daniel DiCorpo
- Laboratory for Quantitative Medicine, Massachusetts General Hospital, Boston, MA, 02115, USA
| | - Ankur Tiwari
- Laboratory for Quantitative Medicine, Massachusetts General Hospital, Boston, MA, 02115, USA.,Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, 02115, USA
| | - Rong Tang
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, 02115, USA
| | - Molly Griffin
- Laboratory for Quantitative Medicine, Massachusetts General Hospital, Boston, MA, 02115, USA
| | - Owen Aftreth
- Department of Urology, Los Angeles Medical Center, Kaiser Permanente, Los Angeles, CA, USA
| | - Pinky Bautista
- Laboratory for Quantitative Medicine, Massachusetts General Hospital, Boston, MA, 02115, USA
| | - Kevin Hughes
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, 02115, USA
| | - Neil Gershenfeld
- MIT Center for Bits and Atoms, Room E15-401, 20 Ames Street, Cambridge, MA, 02139, USA
| | - James Michaelson
- Laboratory for Quantitative Medicine, Massachusetts General Hospital, Boston, MA, 02115, USA. .,Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, 02115, USA. .,Department of Pathology, Massachusetts General Hospital, Boston, MA, 02115, USA. .,Department of Pathology, Harvard Medical School, Boston, MA, 02115, USA. .,, 12 Sheeps Crossing Lane, Woods Hole, USA.
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50
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Affiliation(s)
- Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Eric P. Winer
- Department of Medical Oncology, Dana-Farber Cancer Center, Harvard Medical School, Boston, Massachusetts
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