Does Breast Cancer Subtype Impact Margin Status in Patients Undergoing Partial Mastectomy?

Background Molecular subtype in invasive breast cancer guides systemic therapy. It is unknown whether molecular subtype should also be considered to tailor surgical therapy. The present investigation was designed to evaluate whether breast cancer subtype impacted surgical margins in patients with invasive breast cancer stage I through III undergoing breast-conserving therapy. Methods Data from 2 randomized trials evaluating cavity shave margins (CSM) on margin status in patients undergoing partial mastectomy (PM) were used for this analysis. Patients were included if invasive carcinoma was present in the PM specimen and data for all 3 receptors (ER, PR, and HER2) were known. Patients were classified as luminal if they were ER and/or PR positive; HER2 enriched if they were ER and PR negative but HER2 positive; and TN if they were negative for all 3 receptors. The impact of subtype on the margin status was evaluated at completion of standard PM, prior to randomization to CSM versus no CSM. Non-parametric statistical analyses were performed using SPSS Version 26. Results Molecular subtype was significantly correlated with race ( P = .011), palpability ( P = .007), and grade ( P < .001). Subtype did not correlate with Hispanic ethnicity ( P = .760) or lymphovascular invasion ( P = .756). In this cohort, the overall positive margin rate was 33.7%. This did not vary based on molecular subtype (positive margin rate 33.7% for patients with luminal tumors vs 36.4% for those with TN tumors, P = .425). Discussion Molecular subtype does not predict margin status. Therefore, molecular subtype should not, independent of other factors, influence surgical decision-making.

Specimen Mammography for Intraoperative Margin Assessment in Breast Conserving Surgery: A Meta-Analysis

Specimen mammography is one of the widely used intraoperative methods assessing margin status in breast conserving surgery. We performed a meta-analysis to evaluate the diagnostic accuracy of specimen mammography. Literature databases including Pubmed, Cochrane Library, Web of Science and EMBASE were searched prior to May 2020. 18 studies with a total of 1142 patients were included. Data was extracted to perform pooled analysis, heterogeneity testing, threshold effect testing, sensitivity analysis, publication bias analysis and subgroup analyses. The pooled weighted values were a sensitivity of 0.55 (95% CI, 0.45–0.64), a specificity of 0.85 (95% CI, 0.77–0.90), a DOR of 7 (95% CI, 4–11) and a pooled positive likelihood ratio of 3.6 (95% CI 2.4-5.3). The area under the receiver operator characteristic curve was 0.75 (95% CI 0.71-0.78). In the subgroup analysis, the pooled specificity in the positive margin defined as tumor at margin subgroup was lower than the other positive margin definition subgroup (0.79 [95% CI: 0.66, 0.91] vs. 0.88 [95% CI: 0.81, 0.95], p = 0.01). Our findings indicated specimen mammography to be an accurate and intraoperative imaging technique for margin assessment in breast conserving surgery.

The Versatility of Lateral Chest Wall Perforator Flaps in Immediate and Delayed Breast Reconstruction: Retrospective Study of Clinical Experience with 26 Patients

Rationale: Lateral chest flaps represent versatile reconstructive options, especially valuable in times of global healthcare resource restriction. In this series, we present our experience with the use of lateral chest wall flaps in both immediate and delayed reconstruction from both breast conserving and mastectomy surgery. Methods: A retrospective cohort study of patients who had undergone a lateral chest wall flap for immediate or delayed breast reconstruction of a lumpectomy or mastectomy defect was performed. Data collected consisted of patient demographics, procedure type, tumor/oncological characteristics, as well as postoperative complications. Findings: Between September 2015 and April 2021, 26 patients underwent breast reconstruction using a lateral chest wall flap. Fifteen patients (58%) underwent immediate reconstruction (9 lumpectomy; 6 mastectomy) and 11 (42%) underwent delayed breast reconstruction. All flaps survived, though 1 patient required partial flap debridement following venous compromise hours after surgery. There were no incidences of hematoma, seroma, infection, or wound healing delay at either the donor site or breast. There was one positive margin which occurred in a mastectomy patient. Significance: This study describes the use of lateral chest wall flaps in a wide variety of reconstructive breast surgery scenarios. This technique can be safely performed in an outpatient setting and does not require microvascular techniques. Review of our outcomes and complications demonstrate that this is a safe and effective option. Our experience is that this is an easy to learn, versatile flap that could be a valuable addition to the surgeon's arsenal in breast reconstruction.

Intraoperative Near-Infrared Fluorescence Guided Surgery Using Indocyanine Green (ICG) for the Resection of Sarcomas May Reduce the Positive Margin Rate: An Extended Case Series

Background: Sarcomas are rare, aggressive cancers which can occur in any region of the body. Surgery is usually the cornerstone of curative treatment, with negative surgical margins associated with decreased local recurrence and improved overall survival. Indocyanine green (ICG) is a fluorescent dye which accumulates in sarcoma tissue and can be imaged intraoperatively using handheld near-infrared (NIR) cameras, theoretically helping guide the surgeon’s resection margins. Methods: Patients operated on between 20 February 2019 and 20 October 2021 for intermediate to high grade sarcomas at our centres received either conventional surgery, or were administered ICG pre-operatively followed by intra-operative NIR fluorescence guidance during the procedure. Differences between the unexpected positive margin rates were compared. Results: 115 suitable patients were identified, of which 39 received ICG + NIR fluorescence guided surgery, and 76 received conventional surgery. Of the patients given ICG, 37/39 tumours fluoresced, and surgeons felt the procedure was guided by the intra-operative images in 11 cases. Patients receiving ICG had a lower unexpected positive margin rate (5.1% vs. 25.0%, p = 0.01). Conclusions: The use of NIR fluorescence cameras in combination with ICG may reduce the unexpected positive margin rate for high grade sarcomas. A prospective, multi-centre randomised control trial is now needed to validate these results.

Does conventional specimen radiography after neoadjuvant chemotherapy of breast cancer help to reduce the rate of second surgeries?

Purpose This 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. Methods This 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 and recommend an intraoperative re-excision of any radiologically positive margin. The histological workup of the specimen served as gold standard for the evaluation of the accuracy of CSR and the potential reduction of second surgeries by CSR-guided re-excisions. Results 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 positive predictive value (PPV) of 7.7%, and a negative predictive value (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. Conclusion Positive 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. In summary, CSR after NACT is inadequate for intraoperative margin assessment but remains useful to document removal of the biopsy site clip.

Comparison Among Endoscopic, Laparoscopic, and Open Resection for Relatively Small Gastric Gastrointestinal Stromal Tumors (<5 cm): A Bayesian Network Meta-Analysis

BackgroundEndoscopic resection (ESR) is a novel minimally invasive procedure for superficial tumors. Its safety, efficiency, and outcome for gastric gastrointestinal stromal tumors (gGISTs) less than 5 cm remains unclear compared to laparoscopic resection (LAR) and open resection (ONR). The current network meta-analysis aimed to review and analyze the available evidence of this question.MethodsPubMed, Embase, Cochrane Library, and Web of Science databases were searched to identify eligible studies published up to July 6, 2020. The perioperative and long-term oncological outcomes among ESR, LAR, and ONR for gGIST (&lt;5 cm) were estimated through the Bayesian network meta-analysis with a random-effect model.ResultsFifteen studies with 1,631 patients were included. ESR was associated with a shorter operative time [mean difference, MD: -36; 95% confidence interval, CI (-55, -16)], a higher rate of positive margin [odds ratio, OR: 5.1 × 1010, 95% CI (33, 2.5 × 1032)], and less costs [MD: -1 × 104, 95% CI (-1.6 × 104, -4.4 × 103)] but similar time to resume flatus [MD: 0.52, 95% CI (-0.16, 1.1)] and diet [MD: -3.5, 95% CI (-5.6, -1.6)] compared to LAR. A higher rate of total complications [OR: 11, 95% CI (1.2, 140)] was observed in patients who received ESR compared to patients who received LAR. After excluding perforation from the total complication category, the difference of complication between ESR and LAR disappeared [OR: 0.87, 95% CI (0.22, 2.3)]. The recurrence rate [OR: 1.3, 95% CI (0.40, 4.5)] and disease-free survival [hazard ratio: 1.26, 95% CI (0.60, 2.63)] showed no significant difference between ESR and LAR. ESR was associated with better or equivalent perioperative and long-term outcomes compared to ONR, except for positive margin. A subgroup analysis (&lt;2 and 2–5 cm) showed no significantly different results among these three procedures either.ConclusionESR was shown to be a safe and efficient alternative procedure to both LAR and ONR for gGISTs less than 2 cm and within 2–5 cm, respectively, without worsening the oncologic outcomes. However, preoperative assessment of tumor site is of importance for the determination of procedures regarding the increased incidence of a positive margin related to ESR.

Developing diagnostic assessment of breast lumpectomy tissues using radiomic and optical signatures

High positive margin rates in oncologic breast-conserving surgery are a pressing clinical problem. Volumetric X-ray scanning is emerging as a powerful ex vivo specimen imaging technique for analyzing resection margins, but X-rays lack contrast between non-malignant and malignant fibrous tissues. In this study, combined micro-CT and wide-field optical image radiomics were developed to classify malignancy of breast cancer tissues, demonstrating that X-ray/optical radiomics improve malignancy classification. Ninety-two standardized features were extracted from co-registered micro-CT and optical spatial frequency domain imaging samples extracted from 54 breast tumors exhibiting seven tissue subtypes confirmed by microscopic histological analysis. Multimodal feature sets improved classification performance versus micro-CT alone when adipose samples were included (AUC = 0.88 vs. 0.90; p-value = 3.65e−11) and excluded, focusing the classification task on exclusively non-malignant fibrous versus malignant tissues (AUC = 0.78 vs. 0.85; p-value = 9.33e−14). Extending the radiomics approach to high-dimensional optical data—termed “optomics” in this study—offers a promising optical image analysis technique for cancer detection. Radiomic feature data and classification source code are publicly available.

Adjuvant Radiation Does Not Affect Locoregional Control Following Resection of Melanoma Satellitosis or In-Transit Disease

Background This study evaluates the association of adjuvant radiation therapy (RT) with improved locoregional (LR) recurrence for resected melanoma satellitosis and in-transit disease (ITD). Materials and Methods Data were collected retrospectively for resected melanoma satellitosis/ITD from 1996 to 2017. Results 99 patients were identified. 20 patients (20.2%) received adjuvant RT while 79 (79.8%) did not. Mean follow-up in the RT group was 4.3 years and 4.7 years in the non-RT group. 80% of patients who underwent RT suffered a complication, most commonly dermatitis. Locoregional recurrence occurred in 9 patients (45%) treated with adjuvant RT and 30 patients (38%) in the non-RT group ( P = 0.805). Median LR-DFS was 5.8 years in the RT group and 9.5 years in the non-RT group ( P = 0.604). On multivariable analysis, having a close or positive margin was the only independent predictor of LR-DFS (HR 3.8 95% CI 1.7-8.7). In-transit disease was associated with improved overall survival when compared to satellitosis (HR 0.260, 95% CI 0.08-0.82). Discussion The use of adjuvant RT is not associated with improved locoregional control in resected melanoma satellitosis or ITD. Close or positive margin was the only treatment-related factor associated with decreased LR-DFS after surgical resection of satellitosis/ITD.

Rotated grazing in Brachiaria brizantha cv. marandu to improve milk production

In dairy properties, in order for there to be an increase in profit, it is necessary to increase the efficiency of production factors, especially nutrition, which impacts the fixed cost. Increasingly, a balance is sought between the supply of feed and pasture. The rotational grazing method has been adopted by several producers, as it has good productivity in a smaller area. However, the pastures used in this type of grazing, despite their excellent quality, have higher nutritional requirements. The objective of this work was to carry out an economic analysis of the cost of milk production, through the implantation of rotational grazing, and exchange of native pasture for Brachiaria brizantha cv. marandu, on a family farm. This work was prepared in the city of Foz do Iguaçu. An area of ​​6300m2 was used, divided into 28 paddocks of 225m2 using an electric fence. The total cost of production was R$6,047.40, with a positive margin of R$5.143.61 per year. According to the results obtained in the economic analyses, it is concluded that the implantation of rotational grazing and the exchange of native pasture for Brachiaria brizantha cv. Marandu is a viable management, since the income generated by the sale of milk was sufficient to cover the total costs of production.