Understanding the mechanisms creating false positive lumpectomy margins

Specimen tomosynthesis provides no additional value to specimen ultrasound in ultrasound-visible malignant breast lesions

BACKGROUND

The aim of this study was to evaluate the accuracy and added value of specimen tomosynthesis (ST) to specimen ultrasound (SUS) in margin assessment of excised breast specimens in breast-conserving therapy for non-palpable US-visible breast lesions.

MATERIALS

Between January 2018 and August 2019, all consecutive patients diagnosed with non-palpable breast cancer visible by ultrasound (US), treated with breast-conserving surgery (BCS) and requiring radiological intraoperative breast specimen assessment, were included in this study. Excised breast specimens were examined with SUS by radiologists blinded to the ST results, and margins smaller than 10 mm were recorded. STs were evaluated retrospectively by experienced radiologists.

RESULTS

A total of 120 specimens were included. SUS showed a statistically significant correlation with pathological margin measurements, while ST did not and provided no additional information. The odds ratios (ORs) for SUS to predict a positive margin was 3.429 (confidence interval (CI) = 0.548-21.432) using a 10-mm cut-off point and 14.182 (CI = 2.134-94.254) using a 5-mm cut-off point, while the OR for ST were 2.528 (CI = 0.400-15.994) and 3.188 (CI = 0.318-31.998), respectively.

CONCLUSIONS

SUS was superior in evaluating intraoperative resection margins of US-visible breast resection specimens when compared to ST. Therefore, ST could be considered redundant in applicable situations.

Conventional specimen radiography in breast-conserving therapy: a useful tool for intraoperative margin assessment after neoadjuvant therapy?

PURPOSE

A previous study in our breast unit showed that the diagnostic accuracy of intraoperative specimen radiography and its potential to reduce second surgeries in a cohort of patients treated with neoadjuvant chemotherapy were low, which questions the routine use of Conventional specimen radiography (CSR) in this patient group. This is a follow-up study in a larger cohort to further evaluate these findings.

METHODS

This retrospective study included 376 cases receiving breast-conserving surgery (BCS) after neoadjuvant chemotherapy (NACT) of primary breast cancer. CSR was performed to assess potential margin infiltration and recommend an intraoperative re-excision of any radiologically positive margin. The histological workup of the specimen served as gold standard for the evaluation of the accuracy of CSR and the potential reduction of second surgeries by CSR-guided re-excisions.

RESULTS

362 patients with 2172 margins were assessed. The prevalence of positive margins was 102/2172 (4.7%). CSR had a sensitivity of 37.3%, a specificity of 85.6%, a positive predictive value (PPV) of 11.3%, and a negative predictive value (NPV) of 96.5%. The rate of secondary procedures was reduced from 75 to 37 with a number needed to treat (NNT) of CSR-guided intraoperative re-excisions of 10. In the subgroup of patients with clinical complete response (cCR), the prevalence of positive margins was 38/1002 (3.8%), PPV was 6.5% and the NNT was 34.

CONCLUSION

This study confirms our previous finding that the rate of secondary surgeries cannot be significantly reduced by CSR-guided intraoperative re-excisions in cases with cCR after NACT. The routine use CSR after NACT is questionable, and alternative tools of intraoperative margin assessment should be evaluated.

Ductal carcinoma in situ of the breast: an update for the pathologist in the era of individualized risk assessment and tailored therapies

Ductal carcinoma in situ (DCIS) is a neoplastic proliferation of mammary ductal epithelial cells confined to the ductal-lobular system, and a non-obligate precursor of invasive disease. While there has been a significant increase in the diagnosis of DCIS in recent years due to uptake of mammography screening, there has been little change in the rate of invasive recurrence, indicating that a large proportion of patients diagnosed with DCIS will never develop invasive disease. The main issue for clinicians is how to reliably predict the prognosis of DCIS in order to individualize patient treatment, especially as treatment ranges from surveillance only, breast-conserving surgery only, to breast-conserving surgery plus radiotherapy and/or hormonal therapy, and mastectomy with or without radiotherapy. We conducted a semi-structured literature review to address the above issues relating to "pure" DCIS. Here we discuss the pathology of DCIS, risk factors for recurrence, biomarkers and molecular signatures, and disease management. Potential mechanisms of progression from DCIS to invasive cancer and problems faced by clinicians and pathologists in diagnosing and treating this disease are also discussed. Despite the tremendous research efforts to identify accurate risk stratification predictors of invasive recurrence and response to radiotherapy and endocrine therapy, to date there is no simple, well-validated marker or group of variables for risk estimation, particularly in the setting of adjuvant treatment after breast-conserving surgery. Thus, the standard of care to date remains breast-conserving surgery plus radiotherapy, with or without hormonal therapy. Emerging tools, such as pathologic or biologic markers, may soon change such practice. Our review also includes recent advances towards innovative treatment strategies, including targeted therapies, immune modulators, and vaccines.

Evaluation of discrepancies in weights of fresh and fixed specimens in breast surgery: a retrospective cohort study

BACKGROUND

Handling of breast specimen is not well monitored and there is limited data on the impact of fixative solutions on specimen weights. Weight of resected breast tissue acts as a guide for future reconstructive and symmetrisation procedures. The aim is to quantitatively evaluate the discrepancies in weight of fresh breast specimen and the weight of specimen after being kept in a fixative solution for a variable length of time.

METHODS

Single centre retrospective cohort study including patients undergone breast surgery for both diagnostic and therapeutic purposes between January of 2013 and June 2015. Demographic details were collected from case notes, pathology reports and operation room management information system (ORMIS).

RESULTS

A total of 229 patients with a median age of 63 [interquartile range (IQR) 51-73] years were included. The median body mass index (BMI) was 27.9 (IQR 24.3-31.75) kg/m². Median weight of the fresh specimens was 104 (IQR 44-535) g and that of fixed specimen was 99 (IQR 43-525) g (P value <0.05, Wilcoxon test). The variation was not unidirectional and factors which were important in influencing this variation were: inclusion of overlying skin and larger specimens (P value <0.05, Mann-Whitney U test). Age, BMI, duration of preservation in fixative solution and density of breast did not have significant influence.

CONCLUSIONS

Fixative solution does have significant influence on breast specimen weights. This is more pronounced with heavier specimens and those including overlying skin. It is advisable to measure the weight and volume of fresh breast specimen to aid future surgery with best aesthetic outcome.

AHNS Series: Do you know your guidelines? Principles of surgery for head and neck cancer: A review of the National Comprehensive Cancer Network guidelines

This article continues a series developed by the American Head and Neck Society's Education Committee entitled "Do you know your guidelines?" It is hoped that these features will increase awareness of and adherence to current best practices in head and neck cancer care. In this installment, the National Comprehensive Cancer Network (NCCN) guidelines for surgical therapy are reviewed. © 2016 Wiley Periodicals, Inc. Head Neck 39: 791-796, 2017.

Role of specimen US for predicting resection margin status in breast conserving therapy

AIM

To assess the diagnostic accuracy of specimen ultrasound (US) for predicting resection margin status in women undergoing breast conserving therapy for US-detected cancer, having the histological findings as the reference standard.

PATIENTS AND METHODS

A total of 132 consecutive patients (age range, 34-87 years; mean, 51 years) underwent breast-conserving surgery for US-detected invasive breast cancer. All surgical specimens underwent US examination. The presence of lesion within the specimen and its distance from the specimen margins were assessed considering a threshold distance between the lesion and specimen margins of 10 mm. US findings were then compared with the pathological ones and specimen US. Sensitivity, specificity, diagnostic accuracy, positive (PPV) and negative predictive values (NPV) for predicting histological margin status were evaluated, having the histological findings as the reference standard.

RESULTS

The histological examination detected invasive ductal carcinoma in 96/132 (73%) cases, invasive lobular carcinoma in 32/132 (24%), mucinous carcinoma in 4/132 (3%). The pathological margin analysis revealed 96/132 (73%) negative margins and 36 (27%) close/positive margins. US examination detected all 132 breast lesions within the surgical specimens. 110 (83%) negative margins and 22 (17%) positive margins were found on US. Sensitivity, specificity, diagnostic accuracy, PPV and NPV of 44%, 94%, 80%, 73% and 82%, respectively, were found for specimen US.

CONCLUSIONS

Specimen US represents a time and cost saving imaging tool for evaluating the presence of US detected-breast lesion within surgical specimen and for predicting the histological margin status.

A prospective pilot study of analysis of surgical margins of breast cancers using high-resolution sonography

To investigate the role of high-resolution specimen sonography (SS) to determine the precise location of the targeted lesion in relation to the six surgical margins; the specimen digital radiography isocenter and the correlation with the rate of re-excision and residual tumour. Freshly excised surgical specimens were scanned by a breast radiologist using a high-frequency linear transducer in a cohort of 25 consecutive women undergoing breast conservation. Sonographic measurements of radial distances from all six margins (superior, inferior, lateral, medial, anterior and posterior) were obtained. Sonographic positive margin status was defined as targeted mass identified <5 mm from the tissue edge. The paired t test was used for statistical comparisons between sonographic and pathological measurements. The median cancer size was 15 mm (range 3.80-42 mm; 95 % CI 9.8-18) on sonography and 16 mm (range 2-60 mm; 95 % CI 15-20) on surgical pathology. SS showed 100 % sensitivity and 59 % specificity in the evaluation of surgical pathology margins. 20 % (5 of 25) patients had positive margins where 60 % were in situ carcinoma. The likelihood of carcinoma at the initial surgical margins was significantly higher in dense breasts (3/6 = 50 % vs 1/17 = 5.8 %; p = 0.04). The deviation of the isocenter of the specimens was found not significant. SS is a valuable tool for identify the cancer within the specimen, and better asses the margins. It is of significant importance in patients with dense breasts where specimen radiography is of limited value.

Cost-effectiveness analysis of whole-mount pathology processing for patients with early breast cancer undergoing breast conservation

BACKGROUND

Obtaining accurate histopathologic detail for breast lumpectomy specimens is challenging because of sampling and loss of three-dimensional conformational features with conventional processing. The whole-mount (wm) technique is a novel method of serial pathologic sectioning designed to optimize cross-sectional visualization of resected specimens and determination of margin status.

METHODS

Using a Markov chain cohort simulation cost-effectiveness model, we compared conventional processing with wm technique for breast lumpectomies. Cost-effectiveness was evaluated from the perspective of the Canadian health care system and compared using incremental cost-effectiveness ratios (icers) for cost per quality-adjusted life-year (qaly) over a 10-year time horizon. Deterministic and probabilistic sensitivity analyses were performed to test the robustness of the model with willingness-to-pay (wtp) thresholds of $0-$100,000. Costs are reported in adjusted 2014 Canadian dollars, discounted at a rate of 3%.

RESULTS

Compared with conventional processing, wm processing is more costly ($19,989 vs. $18,427) but generates 0.03 more qalys over 10 years. The icer is $45,414, indicating that this additional amount is required for each additional qaly obtained. The model was robust to all variance in parameters, with the prevalence of positive margins accounting for most of the model's variability.

CONCLUSIONS

After a wtp threshold of $45,414, wm processing becomes cost-effective and ultimately generates fewer recurrences and marginally more qalys over time. Excellent baseline outcomes for the current treatment of breast cancer mean that incremental differences in survival are small. However, the overall benefit of the wm technique should be considered in the context of achieving improved accuracy and not just enhancements in clinical effectiveness.

Lumpectomy specimen margins are not reliable in predicting residual disease in breast conserving surgery

BACKGROUND

In breast conserving surgery, the concordance between lumpectomy margin (LM) status and the status of the corresponding lumpectomy cavity remains uncertain.

METHODS

We analyzed pathology reports of lumpectomies from 2004 to 2006. We included those which contained both ink-directed LM and complete (≥4) separate corresponding shaved cavity margins (SCMs). SCM pathology was used as a surrogate for lumpectomy cavity status, to determine the predictive value of LM for residual disease.

RESULTS

Pathology from 1,201 pairs of LM and SCM from 242 patients was compared. LM status predicted corresponding lumpectomy cavity status with 50.9% sensitivity, 69.5% specificity, 35% positive predictive value, and 81.4% negative predictive value, giving an overall accuracy of 64.9%.

CONCLUSIONS

Oriented LMs are not reliable for predicting lumpectomy cavity status, and therefore not reliable for directing re-excision. Taking complete, oriented SCMs at the time of lumpectomy may improve accuracy compared with traditional LM assessment.

Perioperative measures to optimize margin clearance in breast conserving surgery

Margin status is one of the most important determinants of local recurrence following breast conserving surgery. The fact that up to 60% of patients undergoing breast conserving surgery require re-excision highlights the importance of optimizing margin clearance. In this review we summarize the following perioperative measures that aim to enhance margin clearance: (1) patient risk stratification, specifically risk factors and nomograms, (2) preoperative imaging, (3) intraoperative techniques including wire-guided localization, radioguided surgery, intraoperative ultrasound-guided resection, intraoperative specimen radiography, standardized cavity shaving, and ink-directed focal re-excision; (4) and intraoperative pathology assessment techniques, namely frozen section analysis and imprint cytology. Novel surgical techniques as well as emerging technologies are also reviewed. Effective treatment requires accurate preoperative planning, developing and implementing a consistent definition of margin clearance, and using tools that provide detailed real-time intraoperative information on margin status.

Optimizing surgical margins in breast conservation

Adequate surgical margins in breast-conserving surgery for breast cancer have traditionally been viewed as a predictor of local recurrence rates. There is still no consensus on what constitutes an adequate surgical margin, however it is clear that there is a trade-off between widely clear margins and acceptable cosmesis. Preoperative approaches to plan extent of resection with appropriate margins (in the setting of surgery first as well as after neoadjuvant chemotherapy,) include mammography, US, and MRI. Improvements have been made in preoperative lesion localization strategies for surgery, as well as intraoperative specimen assessment, in order to ensure complete removal of imaging findings and facilitate margin clearance. Intraoperative strategies to accurately assess tumor and cavity margins include cavity shave techniques, as well as novel technologies for margin probes. Ablative techniques, including radiofrequency ablation as well as intraoperative radiation, may be used to extend tumor-free margins without resecting additional tissue. Oncoplastic techniques allow for wider resections while maintaining cosmesis and have acceptable local recurrence rates, however often involve surgery on the contralateral breast. As systemic therapy for breast cancer continues to improve, it is unclear what the importance of surgical margins on local control rates will be in the future.

Involved anterior margins after breast conserving surgery: is re-excision required?

BACKGROUND

Complete tumour excision in breast conserving surgery (BCS) is critical for successful outcome; involved circumferential resection margins are associated with increased disease recurrence. However, the importance of an involved anterior margin (IAM) is less clear. The purpose of this study was to review an aggressive approach to IAM and hence assess whether anterior margin re-excision (RE) yields clinical benefit.

METHODS

A review of prospectively collected clinical and pathology data was performed for all patients who underwent BCS between 2006 and 2010 through a single cancer centre. An involved margin was defined as < 1 mm clearance of invasive or in-situ breast cancer.

RESULTS

1667 patients underwent BCS for invasive and/or in-situ disease, of whom 114 underwent RE. A total of 170 involved margins were identified: most commonly the anterior (52 margins) followed by the posterior (39 margins) and inferior (31 margins) margin. Patients with IAM were more likely to have grade 3 invasive disease (p = 0.0323) but less likely to have residual disease found at re-excision (2/49 vs. 32/101 margins, p = 0.0033); there were no differences when in-situ characteristics were compared.

CONCLUSIONS

RE of IAM after BCS rarely yields further disease; multi-disciplinary teams should consider whether further therapy for an IAM is required on a patient by patient basis.

Clinical series of oncoplastic mastopexy to optimize cosmesis of large-volume resections for breast conservation

BACKGROUND

Oncoplastic mastopexy has been popularized as a method to hide the cosmetic effects of central or large-volume resections associated with breast conservation surgery for breast cancer.

MATERIALS AND METHODS

This review was undertaken to study the uses and limitations of these techniques in providing adequate breast conservation lumpectomy for breast cancer of any stage in a single surgeon's practice. A review of breast cancer cases March 2004 through December 2009 were analyzed for the use of oncoplastic reconstruction in breast conservation surgery.

RESULTS

A total of 167 patients had lumpectomies during this period associated with oncoplastic mastopexy reconstruction. The average age was 55.6 years with a range of 33-85 years. Stage 0 breast cancer accounted for 33 cases (19.8%), and 134 cases were invasive cancers stages 1-3 (stage 1, 34.1%; stage 2, 30.6%; and stage 3, 15.6%). The most common oncoplastic techniques used were, in order of frequency: batwing mastopexy, parallelogram mastopexy, and Modified Wise pattern mastopexy. Positive or close margins (≤ 2 mm) were present in 37 of 167 cases (22%). Positive margins were most associated with higher stage, positive nodes, positive lymphovascular invasion (LVI), use of neoadjuvant chemotherapy, and larger initial T stage, positive estrogen receptor (ER), and younger age. Of these higher stage, node positive, and use of neoadjuvant chemotherapy were statistically significant in this small series (P values = 0.034, 0.016, and 0.022, respectively). Ki-67 and HER2 status were not associated with positive margins. Positive margins were manageable by local re-excision of a solitary face of the prior resection wall in more than 2/3 of cases to achieve negative pathologic margins. Only 11 of 167 required mastectomy because of failure to achieve adequate margins for oncologic control.

CONCLUSIONS

Oncoplastic mastopexy allows the surgeon to address large tumors or tumors in cosmetically difficult sites adequately for breast conservation. Careful margin marking and re-excision of close or positive margins is still often feasible to achieve adequate negative margin with acceptable cosmesis in spite of the large initial volumes of resection.

Correct specimen 3-dimensional orientation in therapeutic mammaplasty to prevent false positive margins

Breast conserving therapy (BCT) is preferred over mastectomy in select cancer patients with the aim of tumour ablation with clear margins and leaving an aesthetically acceptable breast mound. We report on a particular therapeutic mammaplasty where a false positive margin occurred due to the 3-dimensional disorientation of the excised specimen.

Resection margins in ultrasound-guided breast-conserving surgery

BACKGROUND

Few published studies have shown the benefits of intraoperative ultrasound in avoiding inadequate margins in breast-conserving surgery. The aim of this study is to quantify intraoperative ultrasound margin size and assess its relationship to tumor size, multifocality, palpability, histology, and presence of intraductal component.

METHODS

Patients with breast cancer undergoing breast-conserving surgery in whom the operating surgeon visualized the tumor by ultrasound were included. Ultrasound margins measured intraoperatively were prospectively recorded and compared with pathology margins.

RESULTS

Forty-five patients with 48 tumors were included. Twenty five patients (56%) had palpable tumors. Pathologic mean tumor size was 1.9 cm [95% confidence interval (CI) 1.6-2.2 cm, range 0.5-4.8 cm]. There was good correlation between closest margins recorded by ultrasound and pathology margins (r = 0.4674, P < 0.0008). Fourteen patients (31%) had margins re-excised intraoperatively, 12 of them in the direction of the closest pathological margin. Three patients (7%), all of whom had intraoperative re-excision, had a second operation for involved margins without residual cancer on pathological examination of the reoperative specimens. Ultrasound margins ≥0.5 cm achieved adequate pathology margins of ≥0.2 cm in 95% of margins. Overestimation of pathology margins by ultrasound measurement was significantly affected by multifocality (P = 0.0473). Tumor size, palpability, invasive lobular histology, and presence of ductal carcinoma in situ (DCIS) did not cause significant overestimation of pathology margins by ultrasound.

CONCLUSIONS

Intraoperative ultrasound may help maintain a low level of reoperation after breast-conserving surgery. Ultrasound margins <0.5 cm should be re-excised intraoperatively. Reliability of ultrasound in predicting the closest pathology margins was diminished in patients with multifocal tumors.

The effect of simultaneous peripheral excision in breast conservation upon margin status

BACKGROUND

Negative margins in breast conservation therapy (BCT) decrease local recurrence risk. Excision may be performed via two techniques: either as a single lumpectomy specimen or as a central segment with simultaneously resected peripheral segments (PSs). There is little data directly comparing these methods for their effect on margin status.

MATERIALS AND METHODS

A retrospective review of all patients undergoing BCT for invasive breast cancer was conducted to evaluate and compare the two techniques. Presentation, pathologic characteristics, surgical technique, specimen volume, and final margin status were recorded.

RESULTS

Among 259 cancers in 257 women, 33 had positive margins. A single segment was removed in 69 patients, while 190 patients had 1-6 PSs simultaneously removed. By univariate analysis, smaller tumor size (P = .017) and greater numbers of segments removed (P = .01) lowered the risk of positive margins. In a multivariate model, smaller tumor size (P = .0024), lack of EIC (P = .049), and greater numbers of segments removed (P = .0061) lowered the risk of margin positivity. Despite this last predictor, the total resected specimen volume did not increase with the number of PSs removed (P = .4). There was no residual tumor in 49.2% of PSs despite a compromised primary segment margin.

CONCLUSIONS

Smaller tumor size, lack of EIC, and greater numbers of simultaneous PSs excised decrease the likelihood of positive margins, despite a lack of correlation between segment numbers and excised volume. These findings suggest that excision of simultaneous PSs may assist in achieving negative margins, in part, because of avoidance of pathologic artifact.

The effect of intraoperative specimen inking on lumpectomy re-excision rates

Background

Lumpectomy re-excision to obtain negative margins is common. We compare the effect of two specimen orientation approaches on lumpectomy re-excision rates.

Methods

All women undergoing lumpectomy for breast cancer by a single surgeon between 03/2007 - 02/2009 were included. Lumpectomies underwent standard inking (SI) after surgery by a pathologist from 03/2007-02/2008 while intraoperative inking (II) with direct surgeon input was done from 03/2008-02/2009. Rates of margin positivity and re-excision were compared between these methods.

Results

65 patients were evaluated, reflecting SI in 39 and II in 26 cases. Margin positivity rates of 46% [SI] vs. 23% [II] (p = 0.06) and re-excision rates of 38% [SI] vs. 19% [II] were observed. Residual disease at re-excision was found in 27% [SI] vs. 67% [II] of cases.

Conclusions

Intraoperative inking in this practice offered a simple way to reduce re-excision rates after lumpectomy and affect an improvement in quality of patient care.

Standardized and reproducible methodology for the comprehensive and systematic assessment of surgical resection margins during breast-conserving surgery for invasive breast cancer

BACKGROUND

The primary goal of breast-conserving surgery (BCS) is to completely excise the tumor and achieve "adequate" or "negative" surgical resection margins while maintaining an acceptable level of postoperative cosmetic outcome. Nevertheless, precise determination of the adequacy of BCS has long been debated. In this regard, the aim of the current paper was to describe a standardized and reproducible methodology for comprehensive and systematic assessment of surgical resection margins during BCS.

METHODS

Retrospective analysis of 204 BCS procedures performed for invasive breast cancer from August 2003 to June 2007, in which patients underwent a standard BCS resection and systematic sampling of nine standardized re-resection margins (superior, superior-medial, superior-lateral, medial, lateral, inferior, inferior-medial, inferior-lateral, and deep-posterior). Multiple variables (including patient, tumor, specimen, and follow-up variables) were evaluated.

RESULTS

6.4% (13/204) of patients had positive BCS specimen margins (defined as tumor at inked edge of BCS specimen) and 4.4% (9/204) of patients had close margins (defined as tumor within 1 mm or less of inked edge but not at inked edge of BCS specimen). 11.8% (24/204) of patients had at least one re-resection margin containing additional disease, independent of the status of the BCS specimen margins. 7.1% (13/182) of patients with negative BCS specimen margins (defined as no tumor cells seen within 1 mm or less of inked edge of BCS specimen) had at least one re-resection margin containing additional disease. Thus, 54.2% (13/24) of patients with additional disease in a re-resection margin would not have been recognized by a standard BCS procedure alone (P < 0.001). The nine standardized resection margins represented only 26.8% of the volume of the BCS specimen and 32.6% of the surface area of the BCS specimen.

CONCLUSION

Our methodology accurately assesses the adequacy of surgical resection margins for determination of which individuals may need further resection to the affected breast in order to minimize the potential risk of local recurrence while attempting to limit the volume of additional breast tissue excised, as well as to determine which individuals are not realistically amendable to BCS and instead need a completion mastectomy to successfully remove multifocal disease.

Prevalence and predictive factors for the detection of carcinoma in cavity margin performed at the time of breast lumpectomy

Margin resection status is a major risk factor for the development of local recurrence in breast conservation therapy for carcinoma. Tumor bed excision sent as separate orientated cavity margins represents a tool to verify the completeness of the carcinoma resection. We aimed to (1) determine the prevalence of positive cavity margin and its influence on subsequent surgical treatment and (2) identify potential predictive factors for positive cavity margins. From 2003 to 2006, 107 (57 years; 30-88) consecutive patients who underwent a lumpectomy for carcinoma with four orientated cavity margins for carcinoma were selected. Preoperative clinical, radiological and histological data, perioperative macroscopic characteristics and definitive histological analysis results were recorded. Lumpectomy or cavity margins were considered as positive when the distance from carcinoma to the margin was less than or equal to 3 mm. Histological examination of cavity margins showed carcinoma in 38 patients (35%), therefore modifying subsequent surgical therapy in 33 cases. Examination of the cavity margins led (1) to avoiding surgical re-excision in 20 cases (lumpectomy margins were positive and the cavity margins negative), (2) to performing a mastectomy or a re-excision in 13 cases (carcinoma was detected in the cavity margins although the lumpectomy margins were negative or tumor size was superior to 3 cm). Between preoperative and perioperative parameters, US scan and macroscopic size of the tumor were predictive factors for positive cavity margins whereas characteristics of the carcinoma determined on biopsy samples and macroscopic status of the lumpectomy margins were not. Our study confirms that the systematic practice of cavity margin resection avoids surgical re-excision and reduces the likelihood of underestimating the extent of the tumor.

The superficial margin of the skin-sparing mastectomy for breast carcinoma: factors predicting involvement and efficacy of additional margin sampling

BACKGROUND

No study has systematically evaluated the significance of involvement of the superficial specimen margin in skin-sparing mastectomies (SSMs).

METHODS

168 SSMs with a small, additional superficial margin (ASM) specimen taken directly over the tumor to the dermis intraoperatively were studied.

RESULTS

64 SSMs (38%) had a positive superficial specimen margin but only 13 (20%) of these had residual breast carcinoma in ASMs. Only 1 of 104 SSMs with a negative superficial specimen margin had residual breast carcinoma in its ASM (P < 0.05). ASM sampling rendered the final true margin directly over the tumor negative in 54 of 58 (93%) SSMs with a focally positive superficial specimen margin, but did not negate the nonfocally positive superficial specimen margin in six other cases. In SSMs with a positive superficial specimen margin, multivariate analysis revealed that the presence of extensive ductal carcinoma in situ (DCIS) in the SSM and a thicker ASM specimen were the only independent factors predictive of residual breast carcinoma in ASM. Eighty-nine (53%) ASMs contained benign breast tissue.

CONCLUSIONS

Superficial specimen margins in SSMs are often microscopically positive and approximately half of ASMs contain benign breast tissue, likely reflecting the difficulty in completely removing breast tissue near the skin flaps in SSMs. ASM sampling effectively decreases positive superficial specimen margins directly over the tumor in SSMs, but fails to account for positive superficial specimen margins in other quadrants in patients with multicentric disease, especially extensive DCIS. Patients whose superficial margins remain positive could potentially represent a subset of patients for whom postmastectomy radiation is beneficial.

Breast-Conservative Surgery With Close or Positive Margins: Can the Breast Be Preserved With High-Dose-Rate Brachytherapy Boost?

PURPOSE

To evaluate the likelihood of preserving the breast in women who show close or positive margins after conservative surgery for early breast carcinoma.

METHODS AND MATERIALS

Since 1996, 125 women with less than 5 mm or positive margins and positive separate cavity margin sampling were entered in a prospective trial with high-dose radiotherapy. A standard dose of 50 Gy to the whole breast was followed by a high-dose-rate brachytherapy application delivering 3 fractions of 4.4 Gy in 24 hours. The median follow-up was 84 months.

RESULTS

There were only seven local recurrences, with an actuarial local control rate of 95.8% at 5 years and 91.1% at 9 years. Actuarial overall and cause-specific survival rates were 92.6% and 95% at 5 years and 86.7% and 90.4% at 9 years, respectively. Late fibrosis was the most common complication, in 30% of patients, with good or excellent cosmetic results in 77%. The final result was that 95.2% of breasts were preserved.

CONCLUSIONS

Close or positive-margin breast cancer can be well managed with a high-dose boost in a wide tumor bed by means of high-dose-rate brachytherapy. This technique can avoid mastectomy or poor cosmetic resection, with minimal risk of local or general failure.

Management of close margins in invasive breast cancer

Since clinical trials have demonstrated that breast conservation is safe and effective for treatment of invasive breast cancer, there has been considerable disagreement and controversy about what constitutes an acceptable margin in breast cancer. Dogmatic adherence to a set margin for all patients may cause a higher mastectomy rate than necessary, and thus it is important to understand how various clinical and pathologic factors affect local recurrence and outcome. This review discusses that controversy, as well as what factors should be considered when evaluating patients on an individual basis.

The influence of additional surgical margins on the total specimen volume excised and the reoperative rate after breast-conserving surgery

BACKGROUND

It is unclear whether the additional removal of breast tissue during breast-conserving therapy (BCT) for breast cancer beyond the standard lumpectomy reduces the incidence of inadequate microscopic margins found at pathological examination and subsequent reoperation. This study compares the reoperative rates after initial BCT in 3 groups of patients who underwent lumpectomy with complete resection of 4 to 6 additional margins, lumpectomy with selective resection of 1 to 3 additional margins, or standard lumpectomy.

METHODS

Retrospective data were reviewed from 171 selected cases of BCT, from May 2000 to February 2006. Forty-five cases involved lumpectomy with complete resection of 4 to 6 additional margins; 77 involved lumpectomy with selective resection of 1 to 3 additional margins, whereas 49 involved standard lumpectomy. All samples underwent pathologic analysis of inked resection margins by permanent section. The 3 groups were compared for patient demographics, tumor size and histologic subtype, tumor stage, margin status, excised specimen volume, and eventual subsequent reoperation. Adequate surgical margin was defined as any negative margin greater than 2 mm.

RESULTS

The group with complete resection of 4 to 6 additional margins had a subsequent reoperation rate of 17.7%, whereas the group with selective resection of 1 to 3 additional margins and the standard lumpectomy group had a subsequent reoperation rate of 32.5% and 38.7%, respectively, because of inadequate margins. The mean total excised specimen volume in the 3 groups was 129.19, 46.04, and 37.44 cm3, respectively.

CONCLUSIONS

The complete resection of 4 to 6 additional margins during the initial BCT resulted in the lowest subsequent reoperation rate, and the largest total volume specimen excised among the 3 techniques studied.

Influence of breast cancer margin assessment method on the rates of positive margins and residual carcinoma

BACKGROUND

We hypothesized that the method of breast cancer margin assessment may be associated with different rates of positive margins and residual carcinoma.

METHODS

A total of 178 breast cancer specimens were divided into 2 groups (A and B) based on the margin assessment method used. Rates of positive margins, re-excision, and residual carcinoma at re-excision were compared and analyzed statistically.

RESULTS

At least 1 margin was positive in 64.7% in group A and in 65.2% in group B. At directed re-excision 54% in group A and 51% in group B had residual carcinoma. The lateral margin was positive in 44% in group A compared with 26% in group B (P = .06). The posterior margin was positive in 19% in group A and in 51% in group B (P = .001).

CONCLUSIONS

Two different breast cancer specimen margin assessment methods had comparable rates of positive margins and residual carcinoma at re-excision. Different patterns of specific margin positivity suggest that the method of margin assessment may alter results.