Comparative analysis of margin status in breast conservation surgery and its correlation with subsequent re-excision findings

Purpose

Breast-conservation surgery (BCS) has become a standard treatment option for invasive breast carcinoma (IBC) and ductal carcinoma in situ (DCIS). The strongest predictor of local recurrence remains the surgical margin status. We evaluated the margin positivity by quantifying the tumor on positive margins and analyzing the histologic factors including type and extent in determining the likelihood of residual disease upon re-excision.

Method

Retrospective analysis of 210 BCS performed at Mount Sinai Medical Center from the period of January 2011 - December 2017 revealed that 58 had IBC, DCIS, or both, with positive margins that were followed by re-excision.

Result

The margins had IBC in 18 (31%), DCIS in 32 (55.2%) and both in 8 (13%) cases. Thirty-eight cases (65.5%) were free of carcinoma on re-excision. Of 40 cases with margins positive for DCIS, 16 (40%) had residual DCIS. Of 26 cases with IBC at the margins, and 5 had residual disease (19%). This difference was statistically significant (p = 0.002). Of 21 cases with extensive DCIS, 12 had residual disease (p = 0.02) as compared to only 4 out of 19 without extensive DCIS. None of the cases with clinging/micro-papillary DCIS had residual disease, while 51% of the other types (solid, cribriform, come-do) had residual disease (p = 0.02). The area of DCIS as measured on the involved margin correlated with the amount of residual disease on re-excision (p = 0.03).

Conclusion

Margins positive for DCIS are more likely to have residual disease on re-excision in comparison to margins positive for only IBC. The type and extent of DCIS appears to influence the likelihood of residual disease.

Abstract P6-10-04: Factors determining underutilization of core biopsy prior to breast surgery

BACKGROUND:

The American College of Surgeons National Accreditation Program for Breast Centers, Standard 2.9, requires a palpation-guided or image-guided needle biopsy as the initial diagnostic approach for breast cancer rather than an open biopsy. In replacing excisional biopsies, this minimally invasive technique demonstrates accuracy and precision in determining tumor characteristics and allows for more optimal breast cancer care. Recent studies have suggested that needle biopsy is underused in the United States. In a recently published analysis of U.S. Medicare data from 2003-2007, needle biopsy was used in 68.4% of all patients with breast cancer surgery. In this single-institution study, we analyzed the utilization of image-guided preoperative breast biopsies and which patient and system related factors contributed to the underutilization of image-guided breast biopsies and clinical outcomes.

MATERIALS AND METHODS:

In this retrospective study, we analyzed all breast cancer cases diagnosed over a four year period at Mount Sinai Medical Center (MSMC) from January 1, 2009 to December 31, 2013 (n=485). We performed a detailed chart review of the surgical cases that did not meet breast biopsy standards to identify contributing patient and surgeon level factors. Descriptive statistics and univariate analysis were used to characterize breast biopsy patterns and outcomes as well as delineate the associations between patient and surgical covariates with needle biopsy receipt.

RESULTS:

Needle biopsy was used in 86% (n=419) of all breast cancer surgeries. The median age for the cohort of patients without needle biopsy was 68.0 years (range 35-94). There was no significant variation in utilization of needle biopsy by race or surgeon. The proportion of patients without needle biopsy decreased significantly over time from 2009-2013. The most common reason for the lack of preoperative breast biopsy was the surgeon's preference to proceed with surgery because of very suspicious imaging studies (including mammograms and MRI) (n=9). There were an additional nine cases where the biopsy was attempted but was non-diagnostic. The most common patient-related factors for lack of needle biopsy were advanced age, use of anticoagulation and noncompliance due to a psychiatric diagnosis and patient discomfort. Other factors identified include lack of surgeon consultation before biopsy, biopsy of axillary lymph nodes as a means of diagnosis and patient's inpatient status.

CONCLUSIONS:

In this single institution, the rate of needle biopsy for breast cancer diagnosis was above national benchmarks. The most common reason for lack of a preoperative breast biopsy was the surgeon's preference to proceed with surgery because of very suspicious imaging studies. Patients with advanced age, psychiatric history, and inpatient workup were also more likely to lack a preoperative breast biopsy.

Citation Format: Fan T, Paramo J, Mesko T, Poppiti R, Ruiz A, Rodriguez E. Factors determining underutilization of core biopsy prior to breast surgery. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-10-04.

An improved method of flexible endoscopic creation of tracheoesophageal fistula for voice restoration

We present improvements of a previously reported method of tracheoesophageal puncture for voice restoration in postlaryngectomy patients. Our method utilizes a flexible endoscope to enable the tracheoesophageal puncture to be made under direct visualization using only local anesthesia and intravenous sedation. After 3 days, the created tracheoesophageal fistula tract is mature enough to allow placement of a voice prosthesis in the office. This allows the entire procedure to be performed in an outpatient setting with minimal risk.