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Agarwal G, Sattavan S, Vishvak Chanthar KMM, Kumar A, Sabaretnam M, Chand G, Mishra A, Agrawal V. Cost-Efficacy Analysis of Use of Frozen Section Histology for Margin Assessment During Breast Conservation Surgery in Breast Cancer Patients. World J Surg 2023; 47:2457-2463. [PMID: 37386245 DOI: 10.1007/s00268-023-07094-2] [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] [Accepted: 06/12/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Margin assessment is an essential component of breast conservation surgery (BCS). Re-excision of infiltrated margin(s) detected on paraffin section histology (PSH) needs reoperation, adding time, inconvenience and cost. Intra-operative assessment of margins using frozen section histology (IFSH) can potentially obviate need for re-operation, thus facilitating one-step oncologically complete BCS. METHODS IFSH and PSH reports of consecutive patients undergoing BCS (2010-2020) were reviewed. Accuracy and cost-efficacy of IFSH were assessed, considering PSH as gold standard. Cost of achieving oncologically complete BCS in whole cohort with IFSH (Scenario-A) was calculated and compared using appropriate statistical tests, with hospital costs for the cohort in a hypothetical Scenario-B, where IFSH was presumed not to have been used and all patients with infiltrated margin(s) on PSH would have been re-operated. RESULTS Of the 367 patients screened, 39 were excluded due to incomplete IFSH data. Of 328 patients analyzed, 59 (18%) had one or more margins were reported infiltrated on IFSH, managed by re-excision or mastectomy in the same sitting, thus avoiding a reoperation. Additional 8 (2.4%) had involved margins on PSH (False negative IFSH). Significantly higher number of reoperations (p < 0.001) would have been needed in scenario-B. Average cost of the first operation with use of IFSH was Indian Rupees (INR) 25791 which included INR660 as IFSH cost. The average cost of reoperation was INR23724 which could be avoided in 59 (18%) by use of IFSH. The average cost per patient to achieve oncologically complete surgery in scenario A utilizing IFSH was significantly lower (p = 0.001) by INR3101 (11.7%), c.w. that in scenario B. Significant cost-saving with IFSH was maintained in cost-efficacy analysis undertaken with various higher and lower costs assumptions. CONCLUSIONS Use of IFSH facilitates one-step oncologically complete BCS in majority of patients and results in considerable cost saving, resulting in avoidance of reoperations, besides preventing patient anxiety and delay in adjuvant treatment. TRIAL REGISTRATION Clinical Trials Registry-India (CTRI/2021/08/035896).
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Affiliation(s)
- Gaurav Agarwal
- Department of Endocrine and Breast Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Raebareli Road, Lucknow, Uttar Pradesh, 226014, India.
| | - Swati Sattavan
- Department of Endocrine and Breast Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Raebareli Road, Lucknow, Uttar Pradesh, 226014, India
| | - K M M Vishvak Chanthar
- Department of Endocrine and Breast Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Raebareli Road, Lucknow, Uttar Pradesh, 226014, India
| | - Anup Kumar
- Department of Biostatistics and Health Informatics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - M Sabaretnam
- Department of Endocrine and Breast Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Raebareli Road, Lucknow, Uttar Pradesh, 226014, India
| | - Gyan Chand
- Department of Endocrine and Breast Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Raebareli Road, Lucknow, Uttar Pradesh, 226014, India
| | - Anjali Mishra
- Department of Endocrine and Breast Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Raebareli Road, Lucknow, Uttar Pradesh, 226014, India
| | - Vinita Agrawal
- Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Zhao R, Zhang J, Gao J. Blood flow on ultrasound imaging is a predictor of lump margin status in breast-conserving patients: a retrospective matching study. Eur J Med Res 2023; 28:357. [PMID: 37730626 PMCID: PMC10510181 DOI: 10.1186/s40001-023-01356-4] [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: 01/27/2023] [Accepted: 09/10/2023] [Indexed: 09/22/2023] Open
Abstract
PURPOSE This study investigated the relationship between breast ultrasound features and lump margin status in breast-conserving patients. METHODS A single-institution database and medical records system were searched to identify patients who had undergone breast-conserving surgery between 2015 and 2022. Patients were divided into case and control groups based on their postoperative margin status, and different matching methods [case-control matching (CCM) and propensity score matching (PSM)] were used to match the cases and controls at a ratio of 1:1. RESULTS Before matching, patients with positive margins were more likely to have a tumor with increased blood flow (OR = 2.90, 95% CI 1.83-4.61, p < 0.001) and microcalcifications (OR = 2.22, 95% CI 1.44-3.42, p < 0.001). Among the 83 pairs of CCM subjects, patients with positive margins were prone to increased blood flow (p = 0.007) and crab sign (p = 0.040). In addition, there was a significant difference in blood flow (p = 0.030) among PSM subjects. After adjusting for the unbalanced factors, the same results were obtained. CONCLUSIONS Ultrasound blood flow significantly predicts the status of breast-conserving margins, but further studies are required to verify our findings.
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Affiliation(s)
- Rong Zhao
- General Surgery Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030032, China
| | - Jianyong Zhang
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Jinnan Gao
- General Surgery Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030032, China.
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China.
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Wu J, Fan D, Shao Z, Xu B, Ren G, Jiang Z, Wang Y, Jin F, Zhang J, Zhang Q, Ma F, Ma J, Wang Z, Wang S, Wang X, Wang S, Wang H, Wang T, Wang X, Wang J, Wang J, Wang B, Fu L, Li H, Shi Y, Gan L, Liu Y, Liu J, Liu Z, Liu Q, Sun Q, Cheng W, Yu K, Tong Z, Wu X, Song C, Zhang J, Zhang J, Li J, Li B, Li M, Li H, Yang W, Yang H, Yang B, Bu H, Shen J, Shen Z, Chen Y, Chen C, Pang D, Fan Z, Zheng Y, Yu X, Liu G, Hu X, Ling Y, Tang J, Yin Y, Geng C, Yuan P, Gu Y, Chang C, Cao X, Sheng Y, Huang Y, Huang J, Peng W, Zeng X, Xie Y, Liao N. CACA Guidelines for Holistic Integrative Management of Breast Cancer. Holist Integr Oncol 2022; 1:7. [PMID: 37520336 PMCID: PMC9255514 DOI: 10.1007/s44178-022-00007-8] [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] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 05/29/2022] [Indexed: 11/02/2022]
Abstract
Purpose Breast cancer is now the most common malignant tumor worldwide. About one-fourth of female cancer patients all over the world suffer from breast cancer. And about one in six female cancer deaths worldwide is caused by breast cancer. In terms of absolute numbers of cases and deaths, China ranks first in the world. The CACA Guidelines for Holistic Integrative Management of Breast Cancer were edited to help improve the diagnosis and comprehensive treatment in China. Methods The Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used to classify evidence and consensus. Results The CACA Guidelines for Holistic Integrative Management of Breast Cancer include the epidemiology of breast cancer, breast cancer screening, breast cancer diagnosis, early breast cancer treatment, advanced breast cancer treatment, follow-up, rehabilitation, and traditional Chinese medicine treatment of breast cancer patients. Conclusion We to standardize the diagnosis and treatment of breast cancer in China through the formulation of the CACA Guidelines.
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Affiliation(s)
- Jiong Wu
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Daiming Fan
- Department of Gastroenterology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
- State key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
| | - Zhimin Shao
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Binghe Xu
- National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Guosheng Ren
- Department of Endocrine and Breast Surgery, The First Affiliated Hospital of Chongqing Medical University, Yuzhong, Chongqing China
| | - Zefei Jiang
- Medicine-Oncology, The Affiliated Hospital of Military Medical Sciences (The 307th Hospital of Chinese People’s Liberation Army), Beijing, China
| | - Yongsheng Wang
- Breast Disease Center, Shandong Cancer Hospital, Jinan, China
| | - Feng Jin
- Department of Breast Surgery, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Jin Zhang
- The 3rd Department of Breast Cancer, China Tianjin Breast Cancer Prevention, Treatment and Research Center, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center of Cancer, Tianjin, China
| | - Qingyuan Zhang
- Harbin Medical University Cancer Hospital, Harbin, China
| | - Fei Ma
- National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinli Ma
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China
| | - Zhonghua Wang
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Shusen Wang
- Sun Yat-Sen University Cancer Center, Guangzhou, China
| | | | - Shu Wang
- Breast Center, Peking University People’s Hospital, Beijing, China
| | - Haibo Wang
- Department of Breast Center, The Affiliated Hospital of Qingdao University, Shandong, China
| | - Tao Wang
- Department of Oncology, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xiang Wang
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Wang
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jia Wang
- Department of Breast Surgery, Institute of Breast Disease, The Second Hospital of Dalian Medical University, Dalian, Liaoning China
| | - Biyun Wang
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
- Department of Medical Oncology, Fudan University Shanghai Cancer Centre, Shanghai, China
| | - Li Fu
- Department of Breast Cancer Pathology and Research Laboratory, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- Key Laboratory of Breast Cancer Prevention and Therapy, Tianjin Medical University, Ministry of Education, Tianjin, China
- State Key Laboratory of Breast Cancer Research, Tianjin, China
| | - Hongyuan Li
- Department of the Endocrine and Breast Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing Medical University, Chongqing, China
| | - Yehui Shi
- Key Laboratory of Breast Cancer Prevention and Therapy, Tianjin Medical University, Ministry of Education, Tianjin, China
- Department of Breast Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
- Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Lu Gan
- Department of Oncology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yunjiang Liu
- Breast Center, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jian Liu
- Department of Breast Surgery, Affiliated Hangzhou First People’s Hospital, Zhejiang University, School of Medicine, Hangzhou, Zhejiang China
| | - Zhenzhen Liu
- Department of Breast Disease, Henan Breast Cancer Center, Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Qiang Liu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
- Breast Tumor Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Qiang Sun
- Department of Breast Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Wenwu Cheng
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
- Department of Integrated Therapy, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Keda Yu
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Zhongsheng Tong
- Department of Medical Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Xinhong Wu
- Hubei Provincial Clinical Research Center for Breast Cancer, Department of Breast Surgery, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chuangui Song
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jianguo Zhang
- Department of Breast Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang China
| | - Jian Zhang
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
- Department of Medical Oncology, Fudan University Shanghai Cancer Centre, Shanghai, China
| | - Junjie Li
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Bin Li
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China
- Department of Nurse, Cancer Institute and Cancer Center, Fudan University, Shanghai, China
| | - Man Li
- The Second Affiliated Hospital of Dalian Medical University; Institute of Cancer Stem Cell, Dalian Medical University, Dalian, China
| | - Huiping Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Breast Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Wentao Yang
- Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Hongjian Yang
- Department of Breast Surgery, Zhejiang Cancer Hospital, Hangzhou, Zhejiang China
| | - Benlong Yang
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Hong Bu
- Laboratory of Pathology, Key Laboratory of Transplant Engineering and Immunology, NHC, West China Hospital, Sichuan University, Chengdu, China
- Department of Pathology, West China Hospital, Sichuan University, Chengdu, China
| | - Juping Shen
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Zhenzhou Shen
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Yiding Chen
- Department of Breast Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- The Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Zhejiang University School of Medicine, Hangzhou, China
| | - Ceshi Chen
- Key Laboratory of Animal Models and Human Disease Mechanisms of the Chinese Academy of Sciences and Yunnan Province, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming, China
- KIZ-CUHK Joint Laboratory of Bioresources and Molecular Research in Common Diseases, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming, China
- Institute of Translation Medicine, Shenzhen Second People’s Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Da Pang
- Department of Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Zhimin Fan
- Department of Breast Surgery, The First Bethune Hospital of Jilin University, Changchun, Jilin China
| | - Ying Zheng
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
- Department of Cancer Prevention, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Xiaoli Yu
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
- Department of Radiotherapy, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Guangyu Liu
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College of Fudan University, Shanghai, China
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
| | - Xichun Hu
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
- Department of Medical Oncology, Fudan University Shanghai Cancer Centre, Shanghai, China
| | - Yiqun Ling
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
- Department of Nutrition, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Jinhai Tang
- Department of Breast Cancer, Jiangsu Province Hospital, Nanjing, China
| | - Yongmei Yin
- Department of Breast Cancer, Jiangsu Province Hospital, Nanjing, China
| | - Cuizhi Geng
- Department of Breast Surgery, Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Peng Yuan
- National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yajia Gu
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Cai Chang
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
- Department of Medical Ultrasound, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Xuchen Cao
- Key Laboratory of Breast Cancer Prevention and Therapy, Tianjin Medical University, Ministry of Education, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
- Tianjin’s Clinical Research Center for Cancer, Tianjin, China
- The First Department of Breast Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, China
| | - Yuan Sheng
- Department of Breast Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Yuanxi Huang
- Department of Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Jian Huang
- Department of Breast Surgery, Key Laboratory of Tumor Microenvironment and Immune Therapy of Zhejiang Province, Cancer Research Institute of Zhejiang University, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang, China
| | - Weijun Peng
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai, China
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Xiaohua Zeng
- Breast Center, Chongqing Cancer Hospital, Chongqing University, Chongqing, China
| | - Yuntao Xie
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Breast Center, Peking University Cancer Hospital & Institute, Beijing, China
| | - Ning Liao
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong China
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Zhao R, Xing J, Gao J. Development and Validation of a Prediction Model for Positive Margins in Breast-Conserving Surgery. Front Oncol 2022; 12:875665. [PMID: 35646633 PMCID: PMC9133412 DOI: 10.3389/fonc.2022.875665] [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: 02/14/2022] [Accepted: 04/12/2022] [Indexed: 11/21/2022] Open
Abstract
Background The chances of second surgery due to positive margins in patients receiving breast-conversing surgery (BCS) were about 20-40%. This study aims to develop and validate a nomogram to predict the status of breast-conserving margins. Methods The database identified patients with core needle biopsy-proven ductal carcinoma in situ (DCIS) or invasive breast carcinoma who underwent BCS in Shanxi Bethune Hospital between January 1, 2015 and December 31, 2021 (n = 573). The patients were divided into two models: (1) The first model consists of 398 patients who underwent BCS between 2015 and 2019; (2) The validation model consists of 175 patients who underwent BCS between 2020 and 2021. The development of the nomogram was based on the findings of multivariate logistic regression analysis. Discrimination was assessed by computing the C-index. The Hosmer-Lemeshow goodness-of-fit test was used to validate the calibration performance. Results The final multivariate regression model was developed as a nomogram, including blood flow signals (OR = 2.88, p = 0.001), grade (OR = 2.46, p = 0.002), microcalcifications (OR = 2.39, p = 0.003), tumor size in ultrasound (OR = 2.12, p = 0.011) and cerbB-2 status (OR = 1.99, p = 0.042). C-indices were calculated of 0.71 (95% CI: 0.64-0.78) and 0.68 (95% CI: 0.59-0.78) for the modeling and the validation group, respectively. The calibration of the model was considered adequate in the validation group (p > 0.05). Conclusion We developed a nomogram that enables the estimation of the preoperative risk of positive BCS margins. Our nomogram provides a valuable tool for identifying high-risk patients who might have to undergo a wider excision.
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Affiliation(s)
- Rong Zhao
- Department of Breast Surgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
| | - Jun Xing
- Department of Breast Surgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
| | - Jinnan Gao
- Department of Breast Surgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
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Li W, Li X. Development of intraoperative assessment of margins in breast conserving surgery: a narrative review. Gland Surg 2022; 11:258-269. [PMID: 35242687 PMCID: PMC8825505 DOI: 10.21037/gs-21-652] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 09/19/2021] [Accepted: 11/17/2021] [Indexed: 07/28/2023]
Abstract
OBJECTIVE We intend to provide an informative and up-to-date summary on the topic of intraoperative assessment of margins in breast conserving surgery (BCS). Conventional methods as well as cutting-edge technologies are analyzed for their advantages and limitations in the hope that clinicians can turn to this for reference. This review can also offer guidance for technicians in the future design of intraoperative margin assessment tools. BACKGROUND Achieving negative margins during BCS is one of the vital factors for preventing local recurrence. Conducting intraoperative margin assessment can ensure negative margins to a large extent and possibly relieve patients of the anguish of re-interventions. In recent years, innovative methods for margin assessment during BCS are advancing rapidly. And there is a lack of summary regarding the development of intraoperative margin assessment in BCS. METHODS A PubMed search with keywords "intraoperative margin assessment" and "breast conserving surgery" was conducted. Relevant publications were screened manually for its title, abstract and even full text to determine its true relevance. Publications on neo-adjuvant therapy and intraoperative radiotherapy were excluded. References from the searched articles and other supplementary articles were also looked into. CONCLUSIONS Conventional methods for margin assessment yields stable outcome but its use is limited because of the demand on pathology staff and the trade-off between time and precision. Conventional imaging techniques pass the workload to radiologists at the cost of a significantly low duration of time. Involving artificial intelligence for image-based assessment is a further improvement. However, conventional imaging is inherently flawed in that occult lesions can't show on the image and the showing ones are ambiguous and open to interpretation. Unconventional techniques which base their judgment on cellular composition are more reassuring. Nonetheless, unconventional techniques should be subjected to clinical trials before putting into practice. And studies regarding comparison between conventional methods and unconventional methods are also needed to evaluate their relative efficacy.
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Affiliation(s)
- Wanheng Li
- First Clinical Medical School, Southern Medical University, Guangzhou, China
| | - Xiru Li
- Department of General Surgery, The First Medical Center of Chinese PLA General Hospital, Beijing, China
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D'Alfonso TM, Ho DJ, Hanna MG, Grabenstetter A, Yarlagadda DVK, Geneslaw L, Ntiamoah P, Fuchs TJ, Tan LK. Multi-magnification-based machine learning as an ancillary tool for the pathologic assessment of shaved margins for breast carcinoma lumpectomy specimens. Mod Pathol 2021; 34:1487-94. [PMID: 33903728 DOI: 10.1038/s41379-021-00807-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/11/2021] [Accepted: 03/13/2021] [Indexed: 01/19/2023]
Abstract
The surgical margin status of breast lumpectomy specimens for invasive carcinoma and ductal carcinoma in situ (DCIS) guides clinical decisions, as positive margins are associated with higher rates of local recurrence. The "cavity shave" method of margin assessment has the benefits of allowing the surgeon to orient shaved margins intraoperatively and the pathologist to assess one inked margin per specimen. We studied whether a deep convolutional neural network, a deep multi-magnification network (DMMN), could accurately segment carcinoma from benign tissue in whole slide images (WSIs) of shave margin slides, and therefore serve as a potential screening tool to improve the efficiency of microscopic evaluation of these specimens. Applying the pretrained DMMN model, or the initial model, to a validation set of 408 WSIs (348 benign, 60 with carcinoma) achieved an area under the curve (AUC) of 0.941. After additional manual annotations and fine-tuning of the model, the updated model achieved an AUC of 0.968 with sensitivity set at 100% and corresponding specificity of 78%. We applied the initial model and updated model to a testing set of 427 WSIs (374 benign, 53 with carcinoma) which showed AUC values of 0.900 and 0.927, respectively. Using the pixel classification threshold selected from the validation set, the model achieved a sensitivity of 92% and specificity of 78%. The four false-negative classifications resulted from two small foci of DCIS (1 mm, 0.5 mm) and two foci of well-differentiated invasive carcinoma (3 mm, 1.5 mm). This proof-of-principle study demonstrates that a DMMN machine learning model can segment invasive carcinoma and DCIS in surgical margin specimens with high accuracy and has the potential to be used as a screening tool for pathologic assessment of these specimens.
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Chen K, Liu JQ, Wu W, Su FX, Zou Q, Song EW. Clinical practice guideline for breast-conserving surgery in patients with early-stage breast cancer: Chinese Society of Breast Surgery (CSBrS) practice guidelines 2021. Chin Med J (Engl) 2021; 134:2143-2146. [PMID: 34133359 PMCID: PMC8478397 DOI: 10.1097/cm9.0000000000001518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Indexed: 11/25/2022] Open
Affiliation(s)
- Kai Chen
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510120, China
- Department of Breast Surgery, Yat-sen Breast Tumor Hospital, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong 510120, China
| | - Jie-Qiong Liu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510120, China
- Department of Breast Surgery, Yat-sen Breast Tumor Hospital, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong 510120, China
| | - Wei Wu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510120, China
- Department of Breast Surgery, Yat-sen Breast Tumor Hospital, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong 510120, China
| | - Feng-Xi Su
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510120, China
- Department of Breast Surgery, Yat-sen Breast Tumor Hospital, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong 510120, China
| | - Qiang Zou
- Department of Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Er-Wei Song
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510120, China
- Department of Breast Surgery, Yat-sen Breast Tumor Hospital, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong 510120, China
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8
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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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9
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Hanna WM, Parra-Herran C, Lu FI, Slodkowska E, Rakovitch E, Nofech-Mozes S. Ductal carcinoma in situ of the breast: an update for the pathologist in the era of individualized risk assessment and tailored therapies. Mod Pathol 2019; 32:896-915. [PMID: 30760859 DOI: 10.1038/s41379-019-0204-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 12/13/2018] [Accepted: 12/13/2018] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
- Wedad M Hanna
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
| | - Carlos Parra-Herran
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Fang-I Lu
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Elzbieta Slodkowska
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Eileen Rakovitch
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Sharon Nofech-Mozes
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
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10
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Morrow M, Abrahamse P, Hofer TP, Ward KC, Hamilton AS, Kurian AW, Katz SJ, Jagsi R. Trends in Reoperation After Initial Lumpectomy for Breast Cancer: Addressing Overtreatment in Surgical Management. JAMA Oncol 2017; 3:1352-1357. [PMID: 28586788 DOI: 10.1001/jamaoncol.2017.0774] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Importance Surgery after initial lumpectomy to obtain more widely clear margins is common and may lead to mastectomy. Objective To describe surgeons' approach to surgical margins for invasive breast cancer, and changes in postlumpectomy surgery rates, and final surgical treatment following a 2014 consensus statement endorsing a margin of "no ink on tumor." Design, Setting, and Participants This was a population-based cohort survey study of 7303 eligible women ages 20 to 79 years with stage I and II breast cancer diagnosed in 2013 to 2015 and identified from the Georgia and Los Angeles County, California, Surveillance, Epidemiology, and End Results registries. A total of 5080 (70%) returned a survey. Those with bilateral disease, missing stage or treatment data, and with ductal carcinoma in situ were excluded, leaving 3729 patients in the analytic sample; 98% of these identified their attending surgeon. Between April 2015 and May 2016, 488 surgeons were surveyed regarding lumpectomy margins; 342 (70%) responded completely. Pathology reports of all patients having a second surgery and a 30% sample of those with 1 surgery were reviewed. Time trends were analyzed with multinomial regression models. Main Outcomes and Measures Rates of final surgical procedure (lumpectomy, unilateral mastectomy, bilateral mastectomy) and rates of additional surgery after initial lumpectomy over time, and surgeon attitudes toward an adequate lumpectomy margin. Results The 67% rate of initial lumpectomy in the 3729 patient analytic sample was unchanged during the study. The rate of final lumpectomy increased by 13% from 2013 to 2015, accompanied by a decrease in unilateral and bilateral mastectomy (P = .002). Surgery after initial lumpectomy declined by 16% (P < .001). Pathology review documented no significant association between date of treatment and positive margins. Of 342 responding surgeons, 69% endorsed a margin of no ink on tumor to avoid reexcision in estrogen receptor-positive progesterone receptor-positive cancer and 63% for estrogen receptor-negative progesterone- receptor-negative cancer. Surgeons treating more than 50 breast cancers annually were significantly more likely to report this margin as adequate (85%; n = 105) compared with those treating 20 cases or fewer (55%; n = 131) (P < .001). Conclusions and Relevance Additional surgery after initial lumpectomy decreased markedly from 2013 to 2015 concomitant with dissemination of clinical guidelines endorsing a minimal negative margin. These findings suggest that surgeon-led initiatives to address potential overtreatment can reduce the burden of surgical management in patients with cancer.
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Affiliation(s)
- Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Paul Abrahamse
- School of Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Timothy P Hofer
- School of Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor.,Veterans Affairs Center for Clinical Management Research, Health Services Research and Development Service Center of Innovation, Ann Arbor, Michigan
| | - Kevin C Ward
- Department of Epidemiology, Emory University, Rollins School of Public Health, Atlanta, Georgia
| | - Ann S Hamilton
- Keck School of Medicine, Department of Preventive Medicine, University of Southern California, Los Angeles
| | - Allison W Kurian
- Departments of Medicine and Health Research and Policy, Stanford University, Stanford, California
| | - Steven J Katz
- School of Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor.,School of Public Health, Department of Health Management and Policy, University of Michigan, Ann Arbor
| | - Reshma Jagsi
- School of Medicine, Department of Radiation Oncology, University of Michigan, Ann Arbor
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11
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Wu S, Zhu Y, Yang Z, Mo M, Gao H, Yang W, Liu G. Low rate of positive margins and re-excision after partial mastectomy in highly selected breast cancer patients: A Chinese single-institution experience. Oncotarget 2017; 8:12225-33. [PMID: 28103572 DOI: 10.18632/oncotarget.14686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 06/29/2016] [Accepted: 12/27/2016] [Indexed: 11/25/2022] Open
Abstract
A recent randomized controlled trial firstly demonstrated that cavity shaving significantly decreased the rate of positive margins and re-excision among partial mastectomy (PM) patients. However, it remains unknown whether cavity shaving should be routinely applied to Chinese breast cancer patients undergoing PM. A total of 408 PM patients undergoing 410 PMs among 1796 surgically treated breast cancer patients at Fudan University Shanghai Cancer Centre from January 2015 to June 2015 were included in our study. Data were analysed with univariate or multivariate analysis. Overall, 11 of 410 cases (2.7%) had positive margins postoperatively. Moreover, only 24.6% of the cases (P<0.05) presented with ductal carcinoma in situ (DCIS), among whom 10.0% obtained positive margins. In multivariate logistic regression analysis, presence of mammographic calcifications was significantly associated with margin positivity (P<0.05, OR=6.06, 95% CI: 1.53-23.91). In conclusion, cavity shaving during PM should not be routinely performed in Chinese breast cancer patients, particularly in highly selected cases with a low prevalence of DCIS. PM patients with preoperative mammographic calcifications were more likely to have positive margins and might benefit more from cavity shaving.
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12
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Dessain A, Snauwaert C, Baldin P, Deprez P, Libbrecht L, Piessevaux H, Jouret-Mourin A. Endoscopic submucosal dissection specimens in early colorectal cancer: lateral margins, macroscopic techniques, and possible pitfalls. Virchows Arch 2016; 470:165-174. [DOI: 10.1007/s00428-016-2055-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 11/06/2016] [Accepted: 11/29/2016] [Indexed: 01/22/2023]
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13
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Hisada T, Sawaki M, Ishiguro J, Adachi Y, Kotani H, Yoshimura A, Hattori M, Yatabe Y, Iwata H. Impact of intraoperative specimen mammography on margins in breast-conserving surgery. Mol Clin Oncol 2016; 5:269-272. [PMID: 27588192 DOI: 10.3892/mco.2016.948] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [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: 01/29/2016] [Accepted: 05/09/2016] [Indexed: 11/06/2022] Open
Abstract
A positive resection margin is one of the most significant risk factors for local breast cancer recurrence following breast-conserving surgery (BCS). Intraoperative specimen mammography (SMMG) is routinely used to evaluate the surgical margin at our institution. The aim of the present study was to assess the adequacy of SMMG for margin assessment. The patient cohort included 174 women who underwent BCS in 2006. The sensitivity and specificity of SMMG were assessed by comparing the margins assessed by histological and radiological methods. It was also examined whether the rate of positive histological margins was decreased by re-excision following SMMG evaluation. A total of 23 false-negatives and 6 false-positives were determined by SMMG. The sensitivity and specificity of SMMG margin assessment for patients with primary breast cancer were 20.6 and 94.6%, respectively. The positive predictive value was 50% and the negative predictive value was 82.2%. A subgroup analysis revealed that the sensitivity and specificity of SMMG in cases with ductal carcinoma in situ (DCIS) were higher compared with those in invasive ductal carcinoma. Furthermore, the positive histological margin rate was not affected by re-excision. Although the general usefulness of intraoperative SMMG was not proven, this procedure may be useful in specific cases, particularly those with DCIS and those diagnosed by stereotactic biopsy. A prospective study with exact criteria and a standard procedure is required.
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Affiliation(s)
- Tomoka Hisada
- Department of Breast Oncology, Aichi Cancer Center Hospital, Nagoya, Aichi 464-8681, Japan
| | - Masataka Sawaki
- Department of Breast Oncology, Aichi Cancer Center Hospital, Nagoya, Aichi 464-8681, Japan
| | - Junko Ishiguro
- Department of Breast Oncology, Aichi Cancer Center Hospital, Nagoya, Aichi 464-8681, Japan
| | - Yayoi Adachi
- Department of Breast Oncology, Aichi Cancer Center Hospital, Nagoya, Aichi 464-8681, Japan
| | - Haruru Kotani
- Department of Breast Oncology, Aichi Cancer Center Hospital, Nagoya, Aichi 464-8681, Japan
| | - Akiyo Yoshimura
- Department of Breast Oncology, Aichi Cancer Center Hospital, Nagoya, Aichi 464-8681, Japan
| | - Masaya Hattori
- Department of Breast Oncology, Aichi Cancer Center Hospital, Nagoya, Aichi 464-8681, Japan
| | - Yasushi Yatabe
- Department of Pathology and Molecular Diagnostics, Aichi Cancer Center Hospital, Nagoya, Aichi 464-8681, Japan
| | - Hiroji Iwata
- Department of Breast Oncology, Aichi Cancer Center Hospital, Nagoya, Aichi 464-8681, Japan
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14
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Clarke GM, Holloway CMB, Zubovits JT, Nofech-Mozes S, Liu K, Murray M, Wang D, Yaffe MJ. Whole-mount pathology of breast lumpectomy specimens improves detection of tumour margins and focality. Histopathology 2016; 69:35-44. [DOI: 10.1111/his.12912] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 11/27/2015] [Indexed: 11/26/2022]
Affiliation(s)
- Gina M Clarke
- Physical Sciences; Sunnybrook Research Institute; Toronto Ontario Canada
| | - Claire M B Holloway
- Department of Surgery; Sunnybrook Health Sciences Centre; Toronto Ontario Canada
- Department of Surgery; Faculty of Medicine; University of Toronto; Toronto Ontario Canada
| | - Judit T Zubovits
- Department of Pathology; The Scarborough Hospital; Toronto Ontario Canada
- Department of Laboratory Medicine and Pathobiology; University of Toronto; Toronto Ontario Canada
| | - Sharon Nofech-Mozes
- Department of Laboratory Medicine and Pathobiology; University of Toronto; Toronto Ontario Canada
- Department of Anatomic Pathology; Sunnybrook Health Sciences Centre; Toronto Ontario Canada
| | - Kela Liu
- Physical Sciences; Sunnybrook Research Institute; Toronto Ontario Canada
| | - Mayan Murray
- Physical Sciences; Sunnybrook Research Institute; Toronto Ontario Canada
| | - Dan Wang
- Physical Sciences; Sunnybrook Research Institute; Toronto Ontario Canada
| | - Martin J Yaffe
- Physical Sciences; Sunnybrook Research Institute; Toronto Ontario Canada
- Departments of Medical Biophysics and Medical Imaging; University of Toronto; Toronto Ontario Canada
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15
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Jia H, Jia W, Yang Y, Li S, Feng H, Liu J, Rao N, Jin L, Wu J, Gu R, Zhu L, Chen K, Deng H, Zeng Y, Liu Q, Song E, Su F. HER-2 positive breast cancer is associated with an increased risk of positive cavity margins after initial lumpectomy. World J Surg Oncol 2014; 12:289. [PMID: 25241216 PMCID: PMC4190445 DOI: 10.1186/1477-7819-12-289] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [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: 12/13/2013] [Accepted: 09/02/2014] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND The effect of breast cancer subtype on margin status after lumpectomy remains unclear. This study aims to determine whether approximated breast cancer subtype is associated with positive margins after lumpectomy, which could be used to determine if there is an increased risk of developing local recurrence (LR) following breast-conserving surgery. METHODS We studied 1,032 consecutive patients with invasive cancer who received lumpectomies and cavity margin (CM) assessments from January 2003 to November 2012. The following data were collected: patient age, cT stage, pT stage, grade, status of CM, lymph node status, menopausal status, ER, PR, HER-2, and Ki67, as well as the presence of extensive intraductal component (EIC) and lymphovascular invasion (LVI). A χ2 test was used to compare categorical baseline characteristics. Univariate and multivariate logistic regression analyses were performed to evaluate associations between pathologic features of CM status. Kaplan-Meier actuarial cumulative rates of LR (ipsilateral in-breast) were calculated. RESULTS A total of 7,884 pieces of marginal tissue were collected from 1,032 patients, and 209 patients had positive CMs. Of the patients tested, 52.3% had luminal A subtype, 14.9% were luminal B, 12.8% were luminal-HER-2, 8.1% were HER-2 enriched, and 11.8% were triple negative. Univariate analysis showed that EIC (P < 0.001), LVI (P = 0.026), pN stage (N1 vs. N0: P = 0.018; N3 vs. N0: P < 0.001), and luminal B (P = 0.001) and HER-2 (P < 0.001) subtypes were associated with positive CMs. Multivariable analysis indicated that only EIC (P < 0.001), pN stage (P = 0.003), and HER-2 subtype (P < 0.001) were significantly correlated with positive CMs. On multivariable analysis, HER-2 subtype was an independent prognostic factor in LR (P = 0.031). CONCLUSIONS The HER-2 subtype was the predictive factor most associated with positive CMs and an independent prognostic factor for LR. This result suggests that the increased risk of LR in HER-2 breast cancer is due to an increased microscopic invasive tumor burden, which is indicated by margin status after lumpectomy.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Fengxi Su
- Department of Breast Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiangxi Road, Guangzhou 510120, PR China.
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16
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Houssami N, Morrow M. Margins in breast conservation: a clinician's perspective and what the literature tells us. J Surg Oncol 2014; 110:2-7. [PMID: 24756965 DOI: 10.1002/jso.23594] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [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: 01/03/2014] [Accepted: 01/20/2014] [Indexed: 11/06/2022]
Abstract
The optimal margin in breast-conserving surgery is controversial, and re-excision is common. Pathologic margin assessment is not standardized, and tumor biology and the use of systemic therapy have a major impact on local control. A study-level meta-analysis found no difference in local recurrence for margin widths of 1, 2, and 5 mm, leading a multidisciplinary panel to recommend adoption of no ink on tumor as the standard definition of a negative margin.
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Affiliation(s)
- Nehmat Houssami
- Screening and Test Evaluation Program (STEP), School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia; Royal Hospital for Women, Sydney, Australia
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17
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Angarita FA, Nadler A, Zerhouni S, Escallon J. Perioperative measures to optimize margin clearance in breast conserving surgery. Surg Oncol 2014; 23:81-91. [PMID: 24721660 DOI: 10.1016/j.suronc.2014.03.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [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: 11/25/2013] [Revised: 02/28/2014] [Accepted: 03/04/2014] [Indexed: 01/15/2023]
Abstract
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.
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Affiliation(s)
- Fernando A Angarita
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario M5S 1A1, Canada.
| | - Ashlie Nadler
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario M5S 1A1, Canada.
| | - Siham Zerhouni
- Department of Surgery, University of British Columbia, Vancouver, British Columbia V6T 1Z4, Canada.
| | - Jaime Escallon
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario M5S 1A1, Canada; Department of Surgical Oncology, University of Toronto, Princess Margaret Hospital, Toronto, Ontario M5T 2M9, Canada; Marvelle Koffler Breast Centre, Mount Sinai Hospital, Toronto, Ontario M5G 1X5, Canada.
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18
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Moo TA, Choi L, Culpepper C, Olcese C, Heerdt A, Sclafani L, King TA, Reiner AS, Patil S, Brogi E, Morrow M, Van Zee KJ. Impact of margin assessment method on positive margin rate and total volume excised. Ann Surg Oncol 2013; 21:86-92. [PMID: 24046114 DOI: 10.1245/s10434-013-3257-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND For breast-conserving surgery, the method of margin assessment that most frequently achieves negative margins without increasing the volume of tissue excised is uncertain. We examined our institutional experience with three different margin assessment methods used by six experienced breast surgeons. METHODS Patients undergoing breast-conserving surgery for invasive carcinoma during July to December of a representative year during which each method was performed (perpendicular, 2003; tangential, 2004; cavity shave, 2011) were included. The effect of margin method on the positive margin rate at first excision and the total volume excised to achieve negative margins were evaluated by multivariable analysis, by surgeon, and by tumor size and presence of extensive intraductal component (EIC). RESULTS A total of 555 patients were identified, as follows: perpendicular, 140; tangential, 124; and cavity shave, 291. The tangential method had a higher rate of positive margins at first excision than the perpendicular and cavity-shave methods (49, 15, 11 %, respectively; p < 0.0001). Median volumes to achieve negative margins were similar (55 ml perpendicular; 64 ml tangential; 62 ml cavity shave; p = 0.24). Four of six surgeons had the lowest rate of positive margins with the cavity-shave method, which was significant when compared to the tangential method (p < 0.0001) but not the perpendicular method (p = 0.37). The volume excised by the three methods varied by surgeon (p < 0.0001). The perpendicular method was optimal for T1 tumors without EIC; the cavity-shave method tended to be superior for T2-T3 tumors and/or EIC. CONCLUSIONS Although the cavity-shave method may decrease the rates of positive margins, its effect on volume is variable among surgeons and may result in an increase in the total volume excised for some surgeons and for small tumors without EIC.
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Affiliation(s)
- Tracy-Ann Moo
- Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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Russo AL, Arvold ND, Niemierko A, Wong N, Wong JS, Bellon JR, Punglia RS, Golshan M, Troyan SL, Brock JE, Harris JR. Margin status and the risk of local recurrence in patients with early-stage breast cancer treated with breast-conserving therapy. Breast Cancer Res Treat 2013; 140:353-61. [PMID: 23836011 DOI: 10.1007/s10549-013-2627-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 06/28/2013] [Indexed: 11/30/2022]
Abstract
We sought to assess whether a close surgical margin (>0 and <2 mm) after breast-conserving therapy (BCT) confers an increased risk of local recurrence (LR) compared with a widely negative margin (≥2 mm). We studied 906 women with early-stage invasive breast cancer treated with BCT between January 1998 and October 2006; 91 % received adjuvant systemic therapy. Margins were coded as: (1) widely negative (n = 729), (2) close (n = 85), or (3) close (n = 84)/positive (n = 8) but having no additional tissue to remove according to the surgeon. Cumulative incidence of LR and distant failure (DF) were calculated using the Kaplan-Meier method. Gray's competing-risk regression assessed the effect of margin status on LR and Cox proportional hazards regression assessed the effect on DF, controlling for biologic subtype, age, and number of positive lymph nodes (LNs). Three hundred seventy-seven patients (41.6 %) underwent surgical re-excision, of which 63.5 % had no residual disease. With a median follow-up of 87.5 months, the 5-year cumulative incidence of LR was 2.5 %. The 5-year cumulative incidence of LR by margin status was 2.3 % (95 % CI 1.4-3.8 %) for widely negative, 0 % for close, and 6.4 % (95 % CI 2.7-14.6 %) for no additional tissue, p = 0.3. On multivariate analysis, margin status was not associated with LR; however, triple-negative subtype (AHR 3.7; 95 % CI 1.6-8.8; p = 0.003) and increasing number of positive LNs (AHR 1.6; 95 % CI 1.1-2.3; p = 0.025) were associated. In an era of routine adjuvant systemic therapy, close surgical margins and maximally resected close/positive margins were not associated with an increased risk of LR compared to widely negative margins. Additional studies are needed to confirm this finding.
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Affiliation(s)
- Andrea L Russo
- Harvard Radiation Oncology Program, Boston, MA 02215, USA
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20
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Abstract
The twentieth century has witnessed dramatic changes in the surgical management of breast cancer. Herein we focus on the evolution of breast conservation surgery and current surgical trends of lumpectomy, mastectomy and contralateral prophylactic mastectomy. Margin analysis, specimen localization and processing, and the benefits of magnetic resonance imaging remain controversial. Neoadjuvant chemotherapy can offer prognostic information and aid in surgical planning while radiation therapy continues to reduce the risk of local recurrence after breast conserving surgery. Despite these advances, mastectomy remains a popular choice for many women and the use of nipple sparing procedures is increasing. Overall the low rates of local recurrence are attributed to the combination of surgery and targeted adjuvant and radiation therapies.
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Affiliation(s)
- Sarah A McLaughlin
- Department of Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
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Kapoor NS, Eaton A, King TA, Patil S, Stempel M, Morris E, Brogi E, Morrow M. Should Breast Density Influence Patient Selection for Breast-Conserving Surgery? Ann Surg Oncol 2012; 20:600-6. [DOI: 10.1245/s10434-012-2604-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Indexed: 11/18/2022]
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Yang H, Jia W, Chen K, Zeng Y, Li S, Jin L, Wang L, Song E, Su F. Cavity margins and lumpectomy margins for pathological assessment: which is superior in breast-conserving surgery? J Surg Res 2012; 178:751-7. [PMID: 22683081 DOI: 10.1016/j.jss.2012.05.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Revised: 04/06/2012] [Accepted: 05/08/2012] [Indexed: 12/19/2022]
Abstract
PURPOSE This prospective cohort study aimed to compare the efficacy of cavity margins (CMs) and lumpectomy margins (LMs) for pathological assessment in breast-conserving surgery. METHODS We assessed the CMs and LMs of 163 breast cancer patients during breast-conserving surgery. We compared and analyzed the positivity rates of CM and LM. RESULTS The positivity rate of CM at the case level and individual margin level was 30.7% and 8.0%, respectively. The positivity rate of LM was 12.3%, 33.1%, and 45.4% at the case level and 1.8%, 6.2%, and 9.1% at the individual margin level, when we used the National Surgical Adjuvant Breast and Bowel Project criteria (ink-free), 1 mm-free criteria and 2 mm-free criteria, respectively. The positivity rate of LM with 1 mm-free criteria was similar to that of CM. Delivery of neoadjuvant chemotherapy increased the positivity rate of CM (50.0% versus 25.2%; P < 0.01) but not LM (41.6% versus 30.7%; P > 0.05) at the case level, whereas the positivity rate of CM and LM both increased after neoadjuvant chemotherapy at the margin level (CMs: 15.5% versus 5.6%, P < 0.001; and LMs: 10.7% versus 4.9%, P < 0.001). In univariate and multivariate analysis, delivery of neoadjuvant chemotherapy, higher node-positive stage, and presence of ductal carcinoma in situ component were correlated with positive CM, whereas positive human epidermal growth factor receptor 2 status and higher node-positive stage were associated with positive LM. CONCLUSIONS Ink-free criteria may be insufficient for LM assessment in breast-conserving surgery, and at least 1 mm width LM is suggested. After the delivery of neoadjuvant chemotherapy, CM assessment should be routinely performed in addition to LM assessment.
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Affiliation(s)
- Hua Yang
- Department of Breast Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, PR China
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Bathla L, Harris A, Davey M, Sharma P, Silva E. High resolution intra-operative two-dimensional specimen mammography and its impact on second operation for re-excision of positive margins at final pathology after breast conservation surgery. Am J Surg 2011; 202:387-94. [DOI: 10.1016/j.amjsurg.2010.09.031] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2010] [Revised: 09/08/2010] [Accepted: 09/08/2010] [Indexed: 10/17/2022]
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Noguchi M, Inokuchi M, Ohno Y, Yokoi-Noguchi M, Nakano Y, Kosaka T. Oncological and cosmetic outcome in breast cancer patients undergoing "moving window" operation. Breast Cancer Res Treat 2011; 129:849-56. [PMID: 21818589 DOI: 10.1007/s10549-011-1701-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Accepted: 07/26/2011] [Indexed: 10/18/2022]
Abstract
An inappropriate skin incision on the breast reduces the cosmetic benefit of breast-conserving surgery (BCS). To improve the cosmetic outcome, we have performed "moving window" operation in which BCS can be performed via a periareolar incision (periareolar approach) and/or axillary incision (axillary approach) under direct visualization. Axillary lymph node dissection is also performed via an axillary incision. The periareolar and axillary approaches were used in 65 and 43 patients, respectively. Average operation time was 130 min in periareolar approach and 131 min in axillary approach. Average blood loss was 37 and 50 ml, respectively. Postoperatively, the surgical margin of breast tissue was histologically confirmed to be negative in 107 (99%) of 108 patients, one patients underwent subsequently reoperation because of positive surgical margin. Fifty-two patients (85%) in periareolar approach and 37 patients (86%) in axillary approach had excellent or good cosmetic results. With a mean follow-up of 36 months, four patients developed in-breast recurrence, but three of them had neoadjuvant chemotherapy before surgery. The moving window operation can improve cosmetic outcome of BCS without compromising oncological safety. Moreover, it can reduce operation time and blood loss in comparison to endoscope-assisted BCS.
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Affiliation(s)
- Masakuni Noguchi
- Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Uchinada-daigaku 920-0293, Japan.
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Vernet-Tomas MDM, Ortega M, Vidal S, Corominas JM, Carreras R. Factors affecting surgical margins in nonpalpable breast tumors excised with the radioguided occult lesion localization approach. J Obstet Gynaecol Res 2011; 37:422-7. [PMID: 21272155 DOI: 10.1111/j.1447-0756.2010.01374.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM Most breast surgeons generally assume that obtaining negative margins in nonpalpable tumors is a matter of concern. The aim of this study was to examine whether it is easier to obtain negative margins in palpable tumors than in nonpalpable tumors excised with the radioguided occult lesion localization (ROLL) technique. METHODS A retrospective review was made of nonpalpable breast cancers excised with the ROLL technique (ROLL group, n = 83) and palpable breast cancers in which breast conservative therapy was performed (Palpable group, n = 77). The margin status and the size of the minimum margin obtained when it was negative were reviewed. RESULTS The percentage of resections with negative margins was similar in both groups: 51.9% in the Palpable group and 61.4% in the ROLL group. There was no difference between the two groups in the minimum margin obtained: mean ± SD, 5.53 ± 3.146 mm in the Palpable group and 5.96 ± 3.039 mm in the ROLL group. Risk factors for failing to obtain negative margins were analyzed in both groups and were similar. These risk factors included histological grade, extensive intraductal carcinoma and c-erbB2 status. CONCLUSION It is concluded that excision of nonpalpable breast tumors with the ROLL approach obtains similar results for margins as conservative surgery performed for palpable tumors.
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Affiliation(s)
- María del Mar Vernet-Tomas
- Department of Obstetrics and Gynecology, Hospital Universitari del Mar, Autonomous University of Barcelona, Barcelona, Spain.
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Yao K, Stewart AK, Winchester DJ, Winchester DP. Trends in Contralateral Prophylactic Mastectomy for Unilateral Cancer: A Report From the National Cancer Data Base, 1998–2007. Ann Surg Oncol 2010; 17:2554-62. [DOI: 10.1245/s10434-010-1091-3] [Citation(s) in RCA: 205] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2010] [Indexed: 11/18/2022]
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Hodi Z, Ellis IO, Elston CW, Pinder SE, Donovan G, Macmillan RD, Lee AHS. Comparison of margin assessment by radial and shave sections in wide local excision specimens for invasive carcinoma of the breast. Histopathology 2010; 56:573-80. [DOI: 10.1111/j.1365-2559.2010.03518.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Azu M, Abrahamse P, Katz SJ, Jagsi R, Morrow M. What is an adequate margin for breast-conserving surgery? Surgeon attitudes and correlates. Ann Surg Oncol 2010; 17:558-63. [PMID: 19847566 PMCID: PMC3162375 DOI: 10.1245/s10434-009-0765-1] [Citation(s) in RCA: 148] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2009] [Indexed: 01/05/2023]
Abstract
BACKGROUND Re-excision is common in breast-conserving surgery (BCS), partly due to lack of consensus on margin definitions. A population-based surgeon sample was used to determine current attitudes toward margin width and identify characteristics associated with margin choice. METHODS Breast cancer patients treated from 2005 to 2007 were identified from Los Angeles and Detroit Surveillance, Epidemiology, and End Results (SEER) registries. Pathology reports were used to identify their surgeons, who were surveyed (n = 418). Response rate was 74.6% (n = 312). Mean surgeon age was 51.9 years, 17.8% were female, and mean number of years in practice was 18.5. RESULTS Wide variation in margin selection was noted among surgeons, and did not differ for invasive cancer and ductal carcinoma in situ (DCIS). In a scenario of T1 invasive cancer, 11% of surgeons endorsed margins of tumor not touching ink (TNTI), 42% of 1-2 mm, 28% of > or =5 mm, and 19% >1 cm as precluding need for re-excision before radiotherapy. On multivariate analysis, having 50% or more of practice devoted to breast cancer independently predicted smaller margin choice (p = 0.03). For a patient with a 1.4-cm grade 2 estrogen receptor (ER)-positive DCIS without radiotherapy (RT) planned, 3% of surgeons chose TNTI, 12% 1-2 mm, 25% > or =5 mm, and 61% >1 cm as sufficient without re-excision. In the scenario of DCIS without RT, breast specialization independently predicted larger margin choice (p = 0.03). Gender and years in practice were not predictive of margin choice. CONCLUSIONS Wide variation in BCS margin definition exists. Variation is similar for invasive cancer and DCIS with RT, with more specialized surgeons choosing smaller margins. In DCIS without RT, more specialized surgeons favored larger margins. A standardized margin definition may significantly affect re-excision rates.
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Affiliation(s)
- Michelle Azu
- Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Paul Abrahamse
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Steven J. Katz
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Reshman Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
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Romero P, Dauplat MM, Mishellany F, Gimbergues P, Le Bouëdec G, Penault-Llorca F. Chirurgie conservatrice du cancer du sein: évaluation des berges d’exérèse lors de la chirurgie première. ONCOLOGIE 2010. [DOI: 10.1007/s10269-009-1839-1] [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: 11/29/2022]
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Abstract
CONTEXT There is concern that mastectomy is overused in the United States. OBJECTIVES To evaluate the association of patient-reported initial recommendations by surgeons and those given when a second opinion was sought with receipt of initial mastectomy; and to assess the use of mastectomy after attempted breast-conserving surgery (BCS). DESIGN, SETTING, AND PATIENTS A survey of women aged 20 to 79 years with intraductal or stage I and II breast cancer diagnosed between June 2005 and February 2007 and reported to the National Cancer Institute's Surveillance, Epidemiology, and End Results registries for the metropolitan areas of Los Angeles, California, and Detroit, Michigan. Patients were identified using rapid case ascertainment, and Latinas and blacks were oversampled. Of 3133 patients sent surveys, 2290 responded (73.1%). A mailed survey was completed by 96.5% of respondents and 3.5% completed a telephone survey. The final sample included 1984 female patients (502 Latinas, 529 blacks, and 953 non-Hispanic white or other). MAIN OUTCOME MEASURES The rate of initial mastectomy and the perceived reason for its use (surgeon recommendation, patient driven, medical contraindication) and the rate of mastectomy after attempted BCS. RESULTS Of the 1984 patients, 1468 had BCS as an initial surgical therapy (75.4%) and 460 had initial mastectomy, including 13.4% following surgeon recommendation and 8.8% based on patient preference. Approximately 20% of patients (n = 378) sought a second opinion; this was more common for those patients advised by their initial surgeon to undergo mastectomy (33.4%) than for those advised to have BCS (15.6%) or for those not receiving a recommendation for one procedure over another (21.2%) (P < .001). Discordance in treatment recommendations between surgeons occurred in 12.1% (n = 43) of second opinions and did not differ on the basis of patient race/ethnicity, education, or geographic site. Among the 1459 women for whom BCS was attempted, additional surgery was required in 37.9% of patients, including 358 with reexcision (26.0%) and 167 with mastectomy (11.9%). Mastectomy was most common in patients with stage II cancer (P < .001). CONCLUSION Breast-conserving surgery was recommended by surgeons and attempted in the majority of patients evaluated, with surgeon recommendation, patient decision, and failure of BCS all contributing to the mastectomy rate.
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Affiliation(s)
- Monica Morrow
- Breast Surgery Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA.
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Stucky CH, Mclaughlin SA, Dueck AC, Gray RJ, Giurescu ME, Carpenter SG, Grimsby GM, Apsey HA, Pockaj BA. Does magnetic resonance imaging accurately predict residual disease in breast cancer? Am J Surg 2009; 198:547-52. [DOI: 10.1016/j.amjsurg.2009.04.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2009] [Revised: 04/18/2009] [Accepted: 04/18/2009] [Indexed: 01/27/2023]
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Povoski SP, Jimenez RE, Wang WP, Xu RX. Standardized and reproducible methodology for the comprehensive and systematic assessment of surgical resection margins during breast-conserving surgery for invasive breast cancer. BMC Cancer 2009; 9:254. [PMID: 19635166 PMCID: PMC2724549 DOI: 10.1186/1471-2407-9-254] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [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: 04/10/2009] [Accepted: 07/27/2009] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Stephen P Povoski
- Division of Surgical Oncology, Department of Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, 43210, USA
| | - Rafael E Jimenez
- Department of Pathology, The Ohio State University, Columbus, Ohio, 43210, USA
- Current address : Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, 55905, USA
| | - Wenle P Wang
- Department of Pathology, The Ohio State University, Columbus, Ohio, 43210, USA
- Current address : Department of Pathology, VA Medical Center at Baltimore, Baltimore, Maryland, 21201, USA
| | - Ronald X Xu
- Department of Biomedical Engineering, The Ohio State University, Columbus, Ohio, 43210, USA
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Affiliation(s)
- Monica Morrow
- Memorial Sloan-Kettering Cancer Center, York Avenue, New York, NY 10065, USA.
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McLaughlin SA, Ochoa-Frongia LM, Patil SM, Cody HS, Sclafani LM. Influence of frozen-section analysis of sentinel lymph node and lumpectomy margin status on reoperation rates in patients undergoing breast-conservation therapy. J Am Coll Surg 2007; 206:76-82. [PMID: 18155571 DOI: 10.1016/j.jamcollsurg.2007.07.021] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2007] [Revised: 06/29/2007] [Accepted: 07/18/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Frozen-section analysis (FS) of the sentinel lymph node (SLN) is performed to avoid reoperation for axillary lymph node dissection (ALND), but it can miss micrometastatic disease, is labor intensive for the pathologist, and does not alter the number of breast-conservation therapy (BCT) patients needing reoperation for positive margins. The purpose of this study was to determine if eliminating FS would change reoperation rates in BCT patients. STUDY DESIGN Between January 2004 and December 2005, 1,218 patients had simultaneous BCT and SLN biopsy for invasive breast cancer. FS of the SLN was used selectively at the surgeon's discretion. Clinical and pathologic data were collected. RESULTS Overall, 542 of 1,218 (44%) patients had positive margins. FS of the SLN was performed in 931 of 1,218 (76%) patients. In those having FS, the SLN positivity rate was 33% (306 of 931). FS identified the positive SLN in 170 of 306 (56%) patients with positive nodes, allowing for immediate ALND. But 101 of these 170 patients had positive lumpectomy margins; and FS of the SLN saved 69 of 931 (7%) patients a second operation. Of patients not having FS, 48 of 287 (17%) had a positive SLN on final pathology. Only 18 of 48 (those seen on routine hematoxylin and eosin) might have been seen on FS, potentially sparing reoperation. Half of patients not having FS required reexcision for positive margins. FS would have spared reoperation for only 8 of 287 (3%) patients in this group. Overall, of 354 of 1,218 patients with SLN metastases, 170 had immediate ALND and 98 had delayed ALND. Of those having delayed ALND, 68 of 98 also had positive margins. CONCLUSIONS Among patients having BCT with SLN biopsy, FS identified the positive SLN in 56% of patients with positive SLNs, allowing immediate ALND, and was false negative in 44%. Margin status remains a frequent indication for reoperation in BCT; routine FS analysis of the SLN ultimately saves only a minority of patients a second operation.
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Affiliation(s)
- Sarah A McLaughlin
- Department of Breast Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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