Positive Margin and Residual Disease after Breast- Conserving Surgery for Patients with Breast Cancer

Abstract Background Preoperative breast magnetic resonance imaging (MRI) provides more information than mammography and ultrasonography for determining the surgical plan for patients with breast cancer. This study aimed to determine whether breast MRI is more useful for patients with ductal carcinoma in situ (DCIS) lesions than for those with invasive ductal carcinoma (IDC). Methods A total of 1113 patients with breast cancer underwent mammography, ultrasonography, and additional breast MRI before surgery. The patients were divided into 2 groups: DCIS (n = 199) and IDC (n = 914), and their clinicopathological characteristics and oncological outcomes were compared. Breast surgery was classified as follows: conventional breast-conserving surgery (Group 1), partial mastectomy with volume displacement (Group 2), partial mastectomy with volume replacement (Group 3), and total mastectomy with or without reconstruction (Group 4). The initial surgical plan (based on routine mammography and ultrasonography) and final surgical plan (after additional breast MRI) were compared between the 2 groups. The change in surgical plan was defined as group shifting between the initial and final surgical plans. Results Changes (both increasing and decreasing) in surgical plans were more common in the DCIS group than in the IDC group (P < 0.001). These changes may be attributed to the increased extent of suspicious lesions on breast MRI, detection of additional daughter nodules, multifocality or multicentricity, and suspicious findings on mammography or ultrasonography but benign findings on breast MRI. Furthermore, the positive margin incidence in frozen biopsy was not different (P = 0.138). Conclusions Preoperative breast MRI may provide more information for determining the surgical plan for patients with DCIS than for those with IDC.

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13. A Navigated Intelligent Knife for Breast Cancer Surgery

Inquiry@Queen's Undergraduate Research Conference Proceedings ◽

10.24908/iqurcp.11732 ◽

2018 ◽

Author(s):

Mark Asselin

Keyword(s):

Breast Cancer ◽

Tracking System ◽

Treatment Options ◽

Three Dimensional ◽

Positive Margin ◽

Breast Conserving Surgery ◽

Breast Cancer Surgery ◽

Feasibility Trial ◽

Clinical Safety ◽

Surgical Smoke

When a woman is diagnosed with breast cancer, several treatment options are considered including breast conserving surgery. In this type of surgery, the goal is to completely remove the cancer while leaving as much healthy breast tissue as possible. This is a clinical judgement of high consequence since resecting less tissue is cosmetically appealing but increases the chances of leaving cancer cells behind, known as a positive margin. Conventionally, this operation is performed with an electrocautery – imagine it as an electronic knife – which seals tissue as it cuts and produces small amounts of surgical smoke in the process. In most operating rooms today this smoke is treated as a by product, and it is discarded with no further consideration. But this smoke is rich with useful information; it contains traces of the molecules the knife passed through when the smoke was generated. The intelligent knife (iKnife) analyzes this smoke to determine the pathology of tissue the surgeon’s knife has passed through – whether the tissue is cancerous or not. We have coupled the iKnife with an electromagnetic position tracking system to create a three dimensional spatially resolved malignancy map showing where the surgeon’s knife has encountered cancerous tissue. We have developed a functional prototype and have approval for a first clinical safety and feasibility trial. We hope the spatial map will help surgeons to successfully remove the entire malignancy with the smallest amount of healthy tissue while maintaining negative margins – a successful surgical outcome for the patient.

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Does Conventional Specimen Radiography After Neoadjuvant Chemotherapy of Breast Cancer Help To Reduce The Rate of Second Surgeries?

10.21203/rs.3.rs-700849/v1 ◽

2021 ◽

Author(s):

Benedikt Schaefgen ◽

Annika Funk ◽

Peter Sinn ◽

Thomas Bruckner ◽

Christina Gomez Andreu ◽

...

Keyword(s):

Breast Cancer ◽

Neoadjuvant Chemotherapy ◽

False Negative ◽

Positive Margin ◽

Complete Response ◽

Breast Conserving Surgery ◽

Target Lesion ◽

Number Needed To Treat ◽

Positive Margins ◽

Specimen Radiography

Abstract PurposeThis is the first study to systematically evaluate the diagnostic accuracy of intraoperative specimen radiography on margin level and its potential to reduce second surgeries in patients treated with neoadjuvant chemotherapy. MethodsThis retrospective study included 174 cases receiving breast conserving surgery (BCS) after neoadjuvant chemotherapy (NACT) of primary breast cancer. Conventional specimen radiography (CSR) was performed to assess potential margin infiltration of the target lesion and recommend an intraoperative re-excision of any radiologically positive margin. The histological workup of the specimen served as gold standard for the evaluation of the accuracy of CSR and the potential reduction of second surgeries by CSR-guided re-excisions. A subgroup analysis was performed for patients with and without clinical complete response. Results 1044 margins were assessed. Of 47 (4.5%) histopathological positive margins, CSR identified 9 correctly (true positive). 38 infiltrated margins were missed (false negative). This resulted in a sensitivity of 19.2%, a specificity of 89.2%, a PPV of 7.7% and a NPV of 95.9%. The rate of secondary procedures was reduced from 23 to 16 with a number needed to treat (NNT) of CSR guided intraoperative re-excisions of 25. In the subgroup of patients with cCR, the prevalence of positive margins was 10/510 (2.0%), PPV was 1.9% and the NNT was 85. ConclusionPositive margins after NACT are rare and CSR has only a low sensitivity to detect them. Thus, the rate of secondary surgeries cannot be significantly reduced by recommending targeted re-excisions, especially in cases with cCR.

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Systematic Review and Meta-Analysis of the Impact of Intra-Operative Ultrasound Guidance Breast-Conserving Surgery in Early Breast Cancer

Austin Journal of Surgery ◽

10.26420/austinjsurg.2021.1267 ◽

2021 ◽

Vol 8 (2) ◽

Author(s):

Tin SMM ◽

◽

Cheema I ◽

Kurup V ◽

Viswanath YKS ◽

...

Keyword(s):

Breast Cancer ◽

Systematic Review ◽

Early Breast Cancer ◽

Meta Analysis ◽

Positive Margin ◽

Breast Conserving Surgery ◽

Cosmetic Outcome ◽

Ultrasound Guided ◽

Operative Ultrasound ◽

The Impact

Systematic review and meta-analysis of the impact of intra-operative ultrasound guided breast-conserving surgery in early breast cancer. Background: Breast Conservation (BCS) is the standard surgical procedure for early breast cancer. It is challenging for surgeons to achieve adequate excision of the lesion with clear margins and acceptable cosmesis. A continuous Intra-Operative Ultrasound (IOUS) is used during BCS in volume precision surgery. We reviewed its effectiveness to obtain clear margins, low excision volume and better cosmetic outcome during BCS. Methods: We searched three bibliographic databases (MEDLINE, CINAHL, Cochrane Library online) for relevant published and unpublished literature from their inception until December 2019. The randomized controlled trials of the impact of IOUS on excision volume, margin status and cosmetic outcome was assessed, and meta-analysis carried out for margin status with narrative summary was done for other results. Results: This study included four articles in the systematic review. A total of 207 patients with IOUS and 192 patients with Palpation Guided (PGS) BCS was studied in this review. The standardised mean difference of excision volume for 2 trials was -0.31 (-0.62, -0.00) and -0.50 (-0.85, -0.16) with p-value of 0.048 and 0.004. There was no significant volume difference in the remaining two studies. The positive margin rate reduced significantly with IOUS guidance with the pooled OR was 0.19 (95% CI: 0.09, 0.41) with no heterogeneity among studies (p=0.72, I2= 0%). The overall cosmetic outcome favoured satisfaction in both ultrasound-guided and palpation guided BCS groups without significant difference. Conclusion: This study suggests that the use of IOUS provides a statistically significant, less positive margin without a considerable difference in excisional volume. Overall, satisfaction exceeds dissatisfaction with ultrasound-guided Breast-conserving surgery. However, there is insufficient evidence to support the better cosmetic outcome in the IOUS group.

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Can Radiologic Tumor Size Following Neoadjuvant Therapy Reliably Guide Tissue Resection in Breast Conserving Surgery in Patients with Invasive Breast Cancer?

The American Surgeon ◽

10.1177/0003134820964209 ◽

2020 ◽

Vol 86 (10) ◽

pp. 1248-1253

Author(s):

Sarah Walcott-Sapp ◽

Marissa K. Srour ◽

Minna Lee ◽

Michael Luu ◽

Farin Amersi ◽

...

Keyword(s):

Breast Cancer ◽

Neoadjuvant Therapy ◽

Invasive Breast Cancer ◽

Tumor Size ◽

Disease Free Survival ◽

Positive Margin ◽

Breast Conserving Surgery ◽

Breast Cancers ◽

Positive Margin Rate

Optimum tissue resection volume for patients with invasive breast cancer undergoing breast conserving surgery following neoadjuvant therapy (NAT) is not known. We compared positive margin and in-breast tumor recurrence (IBTR) between 2 groups that were created based on radiologic tumor size (RTS (cm3)) at diagnosis, RTS post-NAT, and volume of tissue resected (VTL): Pre-NAT group, patients with VTL closer to RTS at diagnosis, and post-NAT group, patients with VTL closer to post-NAT RTS. 82 patients with 84 breast cancers treated with NAT between 2007 and 2017 who had pre- and post-NAT imaging were identified from a prospectively maintained database. RTS at diagnosis, RTS post-NAT, and VTL were determined. Clinical and treatment characteristics, IBTR, and disease-free survival (DFS) were compared between pre-NAT (n = 51) and post-NAT (n = 33) groups. Compared to post-NAT patients, pre-NAT patients had smaller RTS at presentation (9.2 vs. 33.5 cm3, P < .001) and post-NAT (1.2 vs. 8.2 cm3, P = .024). At median follow-up of 4 years, there were no differences between groups in pathologic tumor size, positive margin rate, adjuvant therapy, IBTR, or DFS. Resection volumes that matched RTS on post-NAT imaging were not associated with increased positive margins or IBTR. It may be appropriate to use post-NAT imaging to guide lumpectomy volume.

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Value of intraoperative frozen section analysis in re-excision margin evaluation in breast-conserving surgery for cancer: a single institution experience

10.21203/rs.3.rs-21408/v1 ◽

2020 ◽

Author(s):

Jian Guo Shen ◽

Lin Bo Wang ◽

Zi Nong Jiang ◽

Xiao Ming Yuan ◽

Wen He Zhao ◽

...

Keyword(s):

Breast Cancer ◽

Ductal Carcinoma ◽

Frozen Section ◽

Positive Margin ◽

Breast Conserving Surgery ◽

Histological Type ◽

Intraoperative Frozen Section ◽

Excision Margin ◽

Frozen Section Analysis ◽

Section Analysis

Abstract Background. Previous studies have demonstrated that in women with breast cancer treated with breast-conserving surgery (BCS), intraoperative frozen section analysis of lumpectomy margins results in a decrease in reoperation rates for margin control. However, the value of intraoperative frozen margin evaluation (FME) in re-excision margin analysis is not fully understood. We analyzed our breast cancer database to identify the value of intraoperative frozen section examination of specimens additionally resected prior to BCS. Methods. We conducted a retrospective review of patients who underwent attempted BCS for breast cancer with routine intraoperative FME at our institution between January 1998 and May 2016. The number of FMEs was analyzed. We additionally analyzed factors associated with positive re-excised margins to identify correlations with patient characteristics. Results. Of the 760 patients who underwent attempted BCS with routinely conducted intraoperative FME, frozen sections were obtained from the initial margin only in 82.5% (n=627), the initial margin as well as a one-time re-excision analysis in 15.8% (n=120), or the initial margin and two or more re-excision analyses in 1.7% (n-13). Based on the results of FME, 727 (95.6%) of the patients underwent BCS, while the remaining 33 (4.4%) converted to mastectomy. Among the patients who underwent BCS, 112 (15.4%) had an initial positive margin on a FME, underwent one-time margin re-excision and achieved a margin-free status, while 1.6% underwent a second margin resection due to a positive result on the first re-excised margin. In total, 72.7% of the conversions to mastectomy were due to a positive initial margin. Univariate and multivariate analyses showed that patients with the ductal carcinoma in situ (DCIS) histological type were more likely to have repeatedly positive re-excised margins during BCS. Conclusion. While routine intraoperative FME of re-excised margins provided only limited value in patients who underwent attempted BCS, this method may be beneficial in the subgroup of patients with the DCIS histological type.

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The Influence of Repeat Surgery and Residual Disease on Recurrence After Breast-Conserving Surgery: A Danish Breast Cancer Cooperative Group Study

Annals of Surgical Oncology ◽

10.1245/s10434-015-4707-9 ◽

2015 ◽

Vol 22 (S3) ◽

pp. 476-485 ◽

Cited By ~ 20

Author(s):

Anne Bodilsen ◽

Karsten Bjerre ◽

Birgitte V. Offersen ◽

Pernille Vahl ◽

Bent Ejlertsen ◽

...

Keyword(s):

Breast Cancer ◽

Residual Disease ◽

Breast Conserving Surgery ◽

Cooperative Group ◽

Repeat Surgery

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Predictive factor for residual tumor after lumpectomy for close margins

Journal of Clinical Oncology ◽

10.1200/jco.2009.27.15_suppl.e11538 ◽

2009 ◽

Vol 27 (15_suppl) ◽

pp. e11538-e11538

Author(s):

V. Ozmen ◽

S. Ozkan Gurdal ◽

M. Muslumanoglu ◽

A. Igci ◽

S. S. Tuzlali ◽

...

Keyword(s):

Breast Cancer ◽

Early Breast Cancer ◽

Ductal Carcinoma ◽

Residual Disease ◽

Surgical Margin ◽

Residual Tumor ◽

Excisional Biopsy ◽

Breast Conserving Surgery ◽

Positive Surgical Margin ◽

Breast Cancer Patients

e11538 Background: It is critical to obtain clear margins to minimize local recurrence after breast conserving surgery(BCS). When re-excisions are performed, there is often no residual disease in the new specimen, calling into question the need for re-excision(s) or mastectomy. The aim of the present study was to identify factors predicting a histologically positive re-excision specimen. Methods: Our prospective breast cancer database was queried for all invasive breast cancer patients who underwent a re-excision lumpectomy for either close or positive margins after an attempt at BCS. Close margins are defined as ≤ 2 mm for invasive carcinoma and presence of ductal carcinoma in situ(DCIS). Clinicopathologic features were correlated with the presence of residual disease in the re-excision specimen. Results: Between February 1997 and August 2008, 2054 patients with early breast cancer underwent surgical treatment in our breast unit. 939(45.7%) of them had BCS. In 543 patients(26.4%), re-excision required due to close margins on the permanent section analysis of their initial surgical specimens. 186 patients(34.3%) had previous excisional biopsy in other clinics. Median age of 543 patients was 50 years. In 290 patients(53.4%), mastectomy was performed due to positive surgical margin or poor cosmetic results. There were no residual tumors in re-excision(65.6 %) or mastectomy(42.4%) specimens of patients. The factors associated with tumor positive re-excision specimen were, age ≤50 years(p=0.044), lymphovascular invasion (p=0.029), multifocality(p<0.001), tumor size >2cm(p=0.008), presence of DCIS(p=0.018), focal margin positivity(p<0.001), DCIS at resection margin(p=0.008) and node positivity (p<0.001). Conclusions: Most of our patients with early breast cancer had unnecessary re-excisions or mastectomy to obtain clear surgical margins. In subset group of patients, re-excision or mastectomy may not be required. No significant financial relationships to disclose.

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