Minimizing re-excision after breast conserving surgery - a review of radiofrequency spectroscopy for real-time, intraoperative margin assessment

INTRODUCTION

For early-stage breast cancer, breast-conserving surgery (BCS) plus radiation is standard-of-care. Nationwide, >20% of BCS patients require re-excision for positive margins, resulting in delayed adjuvant therapy, increased complications, emotional and financial stress for patients, and additional cost to the healthcare system. Although several methods may be employed to mitigate positive margins, no technique can fully address the need. MarginProbe® is an adjunctive tool for real-time intraoperative margin assessment and is shown to reduce positive margins by >50%.

AREAS COVERED

Discussion of the impact of re-excision following BCS, a review of currently available methods for intraoperative margin management, followed by a technology and literature review of the MarginProbe® Radiofrequency Spectroscopy System.

EXPERT OPINION

Re-excision significantly impacts patients, providers and payers. Limitations in the ability to assess margins at time of surgery warrant more advanced methods of residual disease detection. MarginProbe facilitates the most efficient pathway for breast cancer patients through the surgical phase of treatment. The device is well-suited for adoption as the healthcare focus shifts from volume to value and supports the three pillars of the US Department of Health and Human Services' 'Triple-Aim' strategy: improve population health, improve patient experience of care, and reduce per-capita costs.

Breast cancer differential diagnosis using diffuse optical spectroscopic imaging and regression with z-score normalized data

SIGNIFICANCE

Current imaging paradigms for differential diagnosis of suspicious breast lesions suffer from high false positive rates that force patients to undergo unnecessary biopsies. Diffuse optical spectroscopic imaging (DOSI) noninvasively probes functional hemodynamic and compositional parameters in deep tissue and has been shown to be sensitive to contrast between normal and malignant tissues.

AIM

DOSI methods are under investigation as an adjunct to mammography and ultrasound that could reduce false positive rates and unnecessary biopsies, particularly in radiographically dense breasts.

METHODS

We performed a retrospective analysis of 212 subjects with suspicious breast lesions who underwent DOSI imaging. Physiological tissue parameters were z-score normalized to the patient's contralateral breast tissue and input to univariate logistic regression models to discriminate between malignant tumors and the surrounding normal tissue. The models were then used to differentiate malignant lesions from benign lesions.

RESULTS

Models incorporating several individual hemodynamic parameters were able to accurately distinguish malignant tumors from both the surrounding background tissue and benign lesions with area under the curve (AUC) ≥0.85. Z-score normalization improved the discriminatory ability and calibration of these predictive models relative to unnormalized or ratio-normalized data.

CONCLUSIONS

Findings from a large subject population study show how DOSI data normalization that accounts for normal tissue heterogeneity and quantitative statistical regression approaches can be combined to improve the ability of DOSI to diagnose malignant lesions. This improved diagnostic accuracy, combined with the modality's inherent logistical advantages of portability, low cost, and nonionizing radiation, could position DOSI as an effective adjunct modality that could be used to reduce the number of unnecessary invasive biopsies.

Mapping breast cancer blood flow index, composition, and metabolism in a human subject using combined diffuse optical spectroscopic imaging and diffuse correlation spectroscopy

Diffuse optical spectroscopic imaging (DOSI) and diffuse correlation spectroscopy (DCS) are model-based near-infrared (NIR) methods that measure tissue optical properties (broadband absorption, ? a , and reduced scattering, ? s ? ) and blood flow (blood flow index, BFI), respectively. DOSI-derived ? a values are used to determine composition by calculating the tissue concentration of oxy- and deoxyhemoglobin ( HbO 2 , HbR), water, and lipid. We developed and evaluated a combined, coregistered DOSI/DCS handheld probe for mapping and imaging these parameters. We show that uncertainties of 0.3 ?? mm ? 1 (37%) in ? s ? and 0.003 ?? mm ? 1 (33%) in ? a lead to ? 53 % and 9% errors in BFI, respectively. DOSI/DCS imaging of a solid tissue-simulating flow phantom and

Abstract OT3-2-07: Predicting hormonal therapy response in breast cancer using diffuse optical spectroscopic imaging (DOSI): Ongoing clinical study

Background: The goal of this multi-site prospective study is to validate a safe, painless imaging method to measure the change in breast density caused by hormonal chemotherapy treatments such as tamoxifen. Recent studies have demonstrated that hormonal therapies are more effective at reducing risk in women who exhibit >10% reduction in breast density compared to women who had little or no density change, suggesting that breast density is a predictor of tamoxifen effectiveness. Current methods to measure breast density include MRI and mammography, however frequent applications of these modalities are limited due to cost and x-ray exposure, respectively. Alternatively, we are testing an imaging method that uses safe near-infrared light to measure breast tissue physiology called diffuse optical spectroscopic imaging (DOSI).

Trial Design and Eligibility: The primary aim of the study is to determine whether the percentage change in the DOSI measurement of water correlates with the change in the MRI measurement of breast density after 18 months of treatment in the contralateral normal breast of breast cancer patients receiving tamoxifen. Other DOSI-derived parameters such as lipid content and hemoglobin concentration will be examined in secondary aims. Two groups of women are being recruited for the study: Pre-menopausal subjects receiving tamoxifen (treatment group) and pre-menopausal subjects not receiving chemoprevention agents (control group). Participants are measured with DOSI and non-contrast MRI before, and 6, 12 and 18 months after beginning tamoxifen. Eligible subjects are pre- and peri-menopausal females older than 21 years of age who have not and do not intend to receive chemotherapy, radiation, or surgical cancer treatment to the imaged breast, and are not pregnant or nursing. Study sites include the University of California, Irvine and San Francisco campuses.

Statistical Methods: At a 5% significance level, the pre-determined power of the study is sufficient to detect the difference between the treatment and control groups by measuring the percentage change of breast tissue water concentration with DOSI. The research hypothesis is that the mean difference from baseline for tissue water concentration from DOSI will be greater for the tamoxifen-treated group than the control group. For water concentration and for MRI breast density, a two-sided independent sample t-test will be used to test the null hypothesis that the mean difference from baseline is the same for the tamoxifen-treated and control groups. As a secondary analysis, a multivariate mixed effects model will be built using the observed DOSI parameter or MRI breast density measured from each patient as the outcome variable, and predictor variables to include treatment group and measurement time, in addition to relevant clinical and demographic variables.

Accrual Update: Out of the target accrual of 36, 11 subjects (6 treatment and 5 control group) have been enrolled to date. Enrollment is open until 11/30/2015.

Citation Format: Thomas D OSullivan, Anais Leproux, Alice M Police, Dorota Wisner, Christine McLaren, Wen-Pin Chen, Albert E Cerussi, Min-Ying Su, Bruce J Tromberg. Predicting hormonal therapy response in breast cancer using diffuse optical spectroscopic imaging (DOSI): Ongoing clinical study [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr OT3-2-07.

The impact of use of an intraoperative margin assessment device on re-excision rates

Historically there has been a high rate of surgical interventions to obtain clear margins for breast cancer patients undergoing breast conserving local therapy. An intraoperative margin assessment tool (MarginProbe) has been approved for use in the US since 2013. This study is the first compilation of data from routine use of the device, to assess the impact of device utilization on re-excision rates. We present a retrospective, observational, review from groups of consecutive patients, before and after the implementation of intraoperative use of the device during lumpectomy procedures. Lesions were localized by standard methods. The intraoperative margin assessment device was used on all circumferential margins of the main specimen, but not on any additional shavings. A positive reading by the device led to an additional shaving of the corresponding cavity location. Specimens were also, when feasible, imaged intra-operatively by X-ray, and additional shavings were taken if needed based on clinical assessment. For each surgeon, historical re-excision rates were established based on a consecutive set of patients from a time period proximal to initiation of use of the device. From March 2013 to April 2014 the device was routinely used by 4 surgeons in 3 centers. In total, 165 cases lumpectomy cases were performed. Positive margins resulted in additional re-excision procedures in 9.7% (16/165) of the cases. The corresponding historical set from 2012 and 2013 consisted of 186 Lumpectomy cases, in which additional re-excision procedures were performed in 25.8% (48/186) of the cases. The reduction in the rate of re-excision procedures was significant 62% (P < 0.0001). Use of an intraoperative margin assessment device contributes to achieving clear margins and reducing re-excision procedures. As in some cases positive margins were found on shavings, future studies of interest may include an analysis of the effect of using the device on the shavings intra-operatively.

Tungsten targets the tumor microenvironment to enhance breast cancer metastasis

The number of individuals exposed to high levels of tungsten is increasing, yet there is limited knowledge of the potential human health risks. Recently, a cohort of breast cancer patients was left with tungsten in their breasts following testing of a tungsten-based shield during intraoperative radiotherapy. While monitoring tungsten levels in the blood and urine of these patients, we utilized the 66Cl4 cell model, in vitro and in mice to study the effects of tungsten exposure on mammary tumor growth and metastasis. We still detect tungsten in the urine of patients' years after surgery (mean urinary tungsten concentration at least 20 months post-surgery = 1.76 ng/ml), even in those who have opted for mastectomy, indicating that tungsten does not remain in the breast. In addition, standard chelation therapy was ineffective at mobilizing tungsten. In the mouse model, tungsten slightly delayed primary tumor growth, but significantly enhanced lung metastasis. In vitro, tungsten did not enhance 66Cl4 proliferation or invasion, suggesting that tungsten was not directly acting on 66Cl4 primary tumor cells to enhance invasion. In contrast, tungsten changed the tumor microenvironment, enhancing parameters known to be important for cell invasion and metastasis including activated fibroblasts, matrix metalloproteinases, and myeloid-derived suppressor cells. We show, for the first time, that tungsten enhances metastasis in an animal model of breast cancer by targeting the microenvironment. Importantly, all these tumor microenvironmental changes are associated with a poor prognosis in humans.

Laser Doppler velocimetry as a monitor of cardiac output changes in dogs

Cutaneous blood flow may be measured utilizing a continuous, noninvasive technique, laser Doppler velocimetry (LDV). Monitoring of cutaneous blood flow by LDV might be a useful method to monitor cardiac output. To test this hypothesis, sequential measurements of cardiac output, LDV, and transcutaneous oxygen (PtcO2) were made on 10 anesthetized dogs during experimental shock. There was significant correlation between LDV and cardiac output, while PtcO2 reflected cardiac output only at low flow states. These results show that, in the animal model, cutaneous LDV is a sensitive and specific method for monitoring cardiac output changes.

Pulmonary complications after Fluosol administration to patients with life-threatening blood loss

Fluosol-DA 20% (Fluosol), a perfluorochemical emulsion capable of improving oxygen transport, was used to treat three patients with life-threatening hemorrhage. In each case a decreased partial pressure of oxygen, an increased alveolar-arterial oxygen gradient, fever, an increased white blood cell count, and chest x-ray abnormalities occurred at similar time intervals after treatment with Fluosol. In one patient, pulmonary complications were fatal. Similar adverse reactions to treatment with Fluosol have not been previously reported. Possible explanations for these pulmonary complications are the adult respiratory distress syndrome, oxygen toxicity, or direct toxic effects of Fluosol.

Development of gallstone pancreatitis. The role of the common channel

Whether bile reflux through a common channel into the pancreatic duct is a causative factor in the development of gallstone pancreatitis is controversial. To address this issue, we have reviewed a consecutive series of cholecystectomies performed with intraoperative cholangiograms. The cholangiograms and the patients' charts were reviewed independently to determine the incidence of a common channel in patients both with and without pancreatitis and to analyze their clinical courses. The group of patients who had pancreatitis showed a common channel in 19 (90%) of 20 cases, while those patients who did not have pancreatitis showed a common channel in 23 (35%) of 66 cases. The patients who had pancreatitis were less likely to have choledocholithiasis than were those patients who did not have pancreatitis, and these patients were less likely to require exploration of the common bile duct.