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Villemure-Poliquin N, Roy ÈM, Nguyen S, Beauchemin M, Audet N. Tumor Bed Margins Versus Specimen Margins in Oral Cavity Cancer: Too Close to Call? J Otolaryngol Head Neck Surg 2024; 53:19160216241278653. [PMID: 39248608 PMCID: PMC11384533 DOI: 10.1177/19160216241278653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2024] Open
Abstract
INTRODUCTION The routine assessment of intraoperative margins has long been the standard of care for oral cavity cancers. However, there is a controversy surrounding the best method for sampling surgical margins. The aim of our study is to determine the precision of a new technique for sampling tumor bed margins (TBMs), to evaluate the impact on survival and the rate of free flap reconstructions. METHODS This retrospective cohort study involved 156 patients with primary cancer of the tongue or floor of the mouth who underwent surgery as initial curative treatment. Patients were separated into 2 groups: one using an oriented TBM derived from Mohs' technique, where the margins are taken from the tumor bed and identified with Vicryl sutures on both the specimen and the tumor bed, and the other using a specimen margins (SMs) driven technique, where the margins are taken from the specimen after the initial resection. Clinicopathologic features, including margin status, were compared for both groups and correlated with locoregional control. Precision of per-operative TBM sampling method was obtained. RESULTS A total of 156 patients were included in the study, of which 80 were in TBM group and 76 were in SM group. Precision analysis showed that the oriented TBM technique pertained a 50% sensitivity, 96.6% specificity, 80% positive predictive value, and an 87.5% negative predictive value. Survival analysis revealed nonstatistically significant differences in both local control (86.88% vs 83.50%; P = .81) as well as local-regional control (82.57% vs 72.32%; P = .21). There was a significant difference in the rate of free flap-surgeries between the 2 groups (30% vs 64.5%; P < .001). CONCLUSION Our described oriented TBM technique has demonstrated reduced risk of free flap reconstructive surgery, increased precision, and similar prognostic in terms of local control, locoregional control, and disease-free survival when compared to the SM method.
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Affiliation(s)
- Noémie Villemure-Poliquin
- Département d'ophtalmologie et d'oto-rhino-laryngologie - chirurgie cervico-faciale, Faculté de Médecine, Université Laval, Québec, QC, Canada
| | - Ève-Marie Roy
- Département d'ophtalmologie et d'oto-rhino-laryngologie - chirurgie cervico-faciale, Faculté de Médecine, Université Laval, Québec, QC, Canada
| | - Sally Nguyen
- Département de chirurgie, Service d'oto-rhino-laryngologie - chirurgie cervico-faciale, CISSS de l'Outaouais, Centre affilié universitaire avec l'Université McGill, Gatineau, QC, Canada
| | - Michel Beauchemin
- Département d'anatomo-pathologie, Faculté de Médecine, Université Laval, Quebec City, QC, Canada
| | - Nathalie Audet
- Département d'ophtalmologie et d'oto-rhino-laryngologie - chirurgie cervico-faciale, Faculté de Médecine, Université Laval, Québec, QC, Canada
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Fernandez-Pacheco M, Ortmann O, Ignatov A, Inwald EC. Does cavity margin shaving reduce residual tumor and re-excision rates? A systematic review. Arch Gynecol Obstet 2023; 307:1295-1309. [PMID: 35593951 PMCID: PMC10023760 DOI: 10.1007/s00404-022-06512-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 03/06/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Cavity shaving (CS) is a surgical technique used in the treatment of breast cancer (BC). It may reduce margin positivity in histologic assessment and consequently reduces re- excision rates in breast conserving surgery (BCS). The evidence for this assumption is described in the present review. METHODS A systematic review of relevant literature in English from January 1999 to April 2019 was conducted. The analysis included studies on CS and its effects on re-excision rates and margin positivity. We searched PubMed databases for relevant publications. In total, 22 studies were included in the present review. RESULTS The benefit from CS on re-excision rates and histologic margin positivity was variable. Out of 22 studies, 17 reported a reduction in both re-excision rates and histologic margin positivity in margin shaved patients. Four studies could not find a significant reduction of second surgeries and residual tumor rates. One study suggested that CS after BCS was superior to single BCS only in subgroup analysis in IDC tumors. CONCLUSION CS is a surgical technique that was shown to reduce re-excision and margin positivity rates in most of the studies. Furthermore, it can be a useful tool to assess specimen margins and detect multifocality.
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Affiliation(s)
- M Fernandez-Pacheco
- Department of Gynaecology and Obstetrics, University Medical Center Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany.
| | - O Ortmann
- Department of Gynaecology and Obstetrics, University Medical Center Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany
| | - A Ignatov
- Department of Gynaecology and Obstetrics, University Medical Center Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany
| | - E C Inwald
- Department of Gynaecology and Obstetrics, University Medical Center Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany
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3
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Gong P, Chin SL, Allen WM, Ballal H, Anstie JD, Chin L, Ismail HM, Zilkens R, Lakhiani DD, McCarthy M, Fang Q, Firth D, Newman K, Thomas C, Li J, Sanderson RW, Foo KY, Yeomans C, Dessauvagie BF, Latham B, Saunders CM, Kennedy BF. Quantitative Micro-Elastography Enables In Vivo Detection of Residual Cancer in the Surgical Cavity during Breast-Conserving Surgery. Cancer Res 2022; 82:4093-4104. [PMID: 36098983 PMCID: PMC9627129 DOI: 10.1158/0008-5472.can-22-0578] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/29/2022] [Accepted: 09/08/2022] [Indexed: 01/07/2023]
Abstract
Breast-conserving surgery (BCS) is commonly used for the treatment of early-stage breast cancer. Following BCS, approximately 20% to 30% of patients require reexcision because postoperative histopathology identifies cancer in the surgical margins of the excised specimen. Quantitative micro-elastography (QME) is an imaging technique that maps microscale tissue stiffness and has demonstrated a high diagnostic accuracy (96%) in detecting cancer in specimens excised during surgery. However, current QME methods, in common with most proposed intraoperative solutions, cannot image cancer directly in the patient, making their translation to clinical use challenging. In this proof-of-concept study, we aimed to determine whether a handheld QME probe, designed to interrogate the surgical cavity, can detect residual cancer directly in the breast cavity in vivo during BCS. In a first-in-human study, 21 BCS patients were scanned in vivo with the QME probe by five surgeons. For validation, protocols were developed to coregister in vivo QME with postoperative histopathology of the resected tissue to assess the capability of QME to identify residual cancer. In four cavity aspects presenting cancer and 21 cavity aspects presenting benign tissue, QME detected elevated stiffness in all four cancer cases, in contrast to low stiffness observed in 19 of the 21 benign cases. The results indicate that in vivo QME can identify residual cancer by directly imaging the surgical cavity, potentially providing a reliable intraoperative solution that can enable more complete cancer excision during BCS. SIGNIFICANCE Optical imaging of microscale tissue stiffness enables the detection of residual breast cancer directly in the surgical cavity during breast-conserving surgery, which could potentially contribute to more complete cancer excision.
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Affiliation(s)
- Peijun Gong
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia.,Corresponding Author: Peijun Gong, BRITElab, Harry Perkins Institute of Medical Research, Perth 6009, Australia. Phone: 61-8-6488-6774; E-mail:
| | - Synn Lynn Chin
- Breast Centre, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Wes M. Allen
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Helen Ballal
- Breast Centre, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - James D. Anstie
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Lixin Chin
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Hina M. Ismail
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Renate Zilkens
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Division of Surgery, Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Devina D. Lakhiani
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | | | - Qi Fang
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Daniel Firth
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Kyle Newman
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Caleb Thomas
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Jiayue Li
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia.,Australian Research Council Centre for Personalised Therapeutics Technologies, Melbourne, Victoria, Australia
| | - Rowan W. Sanderson
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Ken Y. Foo
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Chris Yeomans
- PathWest, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Benjamin F. Dessauvagie
- PathWest, Fiona Stanley Hospital, Murdoch, Western Australia, Australia.,Division of Pathology and Laboratory Medicine, Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Bruce Latham
- PathWest, Fiona Stanley Hospital, Murdoch, Western Australia, Australia.,The University of Notre Dame, Fremantle, Western Australia, Australia
| | - Christobel M. Saunders
- Breast Centre, Fiona Stanley Hospital, Murdoch, Western Australia, Australia.,Division of Surgery, Medical School, The University of Western Australia, Perth, Western Australia, Australia.,Breast Clinic, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Brendan F. Kennedy
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia.,Australian Research Council Centre for Personalised Therapeutics Technologies, Melbourne, Victoria, Australia
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Fernández-Pacheco M, Gerken M, Ortmann O, Ignatov A, Klinkhammer-Schalke M, Hatzipanagiotou ME, Inwald EC. Impact of cavity shaving on residual tumor rates in patients with primary invasive carcinoma and carcinoma in situ in breast conserving surgery. Arch Gynecol Obstet 2022; 307:1573-1583. [PMID: 36282347 PMCID: PMC10110683 DOI: 10.1007/s00404-022-06803-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/19/2022] [Indexed: 11/26/2022]
Abstract
Abstract
Background
Several international studies reported relatively high re-excision rates due to residual tumor in breast conserving surgery (BCS). Cavity shaving (CS) is a surgical strategy to reduce re-excision rates. This study aimed to investigate the effect of circumferential cavity shaving during BCS to reduce residual tumor.
Material and Methods
A total of 591 patients with early invasive carcinoma or carcinoma in situ of the breast (ICD-10, C50 or D05) who were diagnosed between 01/01/2017 and 31/12/2019 and underwent BCS in a certified breast cancer center of the University Regensburg were analyzed regarding surgical excision methods. Patients with CS during BCS and patients with targeted re-excision in a specific direction depending on the result of intraoperative mammography or sonography during BCS were compared. The risk of pathologic residual tumor (R1) was compared between both groups by means of a multivariable binary logistic regression model to determine if there is a benefit of a certain surgical method to avoid a second intervention for re-excision. We adjusted for age, tumor size, nodal status, histologic type, surgeon, breast side, and neoadjuvant chemotherapy.
Results
80 (n = 13.54%) patients had CS and 511 (n = 86.46%) had a targeted re-excision in a specific direction during BCS according to intraoperative mammography or sonography. After comparing both techniques in a multivariable regression model, there was no significant difference regarding risk of residual tumor (p = 0.738) in the total cohort. However, CS showed a tendency to be favorable regarding rates of residual tumor in patients with invasive breast cancer between 60 and 70 years (p = 0.072) and smaller T1-tumors (p = 0.057) compared to targeted intraoperative re-excision following mammographic or sonographic assessment.
Conclusion
CS showed a tendency to reduce residual tumor compared to the standard technique of intraoperative re-excision in specific subgroups, although no statistical significance was reached. Further studies are needed to overcome potential limitations like surgeon-based bias and missing standardized definitions of CS to reduce residual tumor rates.
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Affiliation(s)
- Miriam Fernández-Pacheco
- Department of Gynecology and Obstetrics, University Medical Center Regensburg, Regensburg, Germany.
| | - Michael Gerken
- Tumor Center - Institute for Quality Management and Health Services Research, University of Regensburg, Regensburg, Germany
- Bavarian Cancer Registry, Regional Centre Regensburg, Bavarian Health and Food Safety Authority, Regensburg, Germany
| | - Olaf Ortmann
- Department of Gynecology and Obstetrics, University Medical Center Regensburg, Regensburg, Germany
| | - Atanas Ignatov
- Department of Gynecology and Obstetrics, Otto-Von-Guericke University, Magdeburg, Germany
| | - Monika Klinkhammer-Schalke
- Tumor Center - Institute for Quality Management and Health Services Research, University of Regensburg, Regensburg, Germany
- Bavarian Cancer Registry, Regional Centre Regensburg, Bavarian Health and Food Safety Authority, Regensburg, Germany
| | | | - Elisabeth C Inwald
- Department of Gynecology and Obstetrics, University Medical Center Regensburg, Regensburg, Germany
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Delannoy L, Foulon A, Naepels P, Mancaux A, Théret P, Sergent F. [Interest of systematic shavings to reduce reoperation in breast-conserving surgery of breast cancer]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2022; 50:395-401. [PMID: 34896637 DOI: 10.1016/j.gofs.2021.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 12/03/2021] [Accepted: 12/03/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE The INCa and HAS have developed quality and safety indicators for care specific to breast cancer. Among these, in the conservative surgery of this cancer includes the reoperation rate: target˂10%, alert>20%. The main objective of our study was to evaluate whether the practice of systematic recuts still called "shaving" would meet the objectives of the indicators. METHODS Observational, retrospective, single-center study over two years in a regional referral center. Two groups of patients were compared: one with "shaving" and one without (no shaving or oriented shaving). RESULTS In total, 381 patients were operated on, including 48 (12.6%) with shaving and 333 (87.4%) without. Revision rates for damaged margins were 18.75% (9/48) in the shaving group which met the quality criterias vs. 23.7% (79/333) which did not satisfy them; P=0.4. Furthermore, the rate of discovery of occult sites on recuts was higher in the shaving group: 22.9% (11/48) vs. 9.9% (33/333); P=0.02. In the shaving group, 10.4% (5/48) of the patients were resected again for damaged margins for the initial cancer vs. 18.6% (62/333) in the group without shaving; P=0.23. CONCLUSION Our study confirms the interest of performing "shaving" to meet the requirements of the INCa and HAS quality criteria. The absence of systematic cross-sectioning leads to the risk of not recognizing the existence of occult sites. However, the discovery of occult cancers does not significantly reduce the rate of repeat surgery.
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Affiliation(s)
- L Delannoy
- Service de gynécologie-obstétrique et médecine de la reproduction, CHU d'Amiens-Picardie Site Sud, 1, rond-point du Professeur Christian-Cabrol, 80054 Amiens cedex 1, France
| | - A Foulon
- Service de gynécologie-obstétrique et médecine de la reproduction, CHU d'Amiens-Picardie Site Sud, 1, rond-point du Professeur Christian-Cabrol, 80054 Amiens cedex 1, France; Université Picardie Jules-Verne, 1, chemin du Thil - CS 52501, Amiens cedex 1, France
| | - P Naepels
- Service de gynécologie-obstétrique et médecine de la reproduction, CHU d'Amiens-Picardie Site Sud, 1, rond-point du Professeur Christian-Cabrol, 80054 Amiens cedex 1, France
| | - A Mancaux
- Service de gynécologie-obstétrique et médecine de la reproduction, CHU d'Amiens-Picardie Site Sud, 1, rond-point du Professeur Christian-Cabrol, 80054 Amiens cedex 1, France
| | - P Théret
- Service de gynécologie-obstétrique et médecine de la reproduction, CHU d'Amiens-Picardie Site Sud, 1, rond-point du Professeur Christian-Cabrol, 80054 Amiens cedex 1, France
| | - F Sergent
- Service de gynécologie-obstétrique et médecine de la reproduction, CHU d'Amiens-Picardie Site Sud, 1, rond-point du Professeur Christian-Cabrol, 80054 Amiens cedex 1, France; Université Picardie Jules-Verne, 1, chemin du Thil - CS 52501, Amiens cedex 1, France.
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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] [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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Resection of Cavity Shave Margins in Stage 0-III Breast Cancer Patients Undergoing Breast Conserving Surgery: A Prospective Multicenter Randomized Controlled Trial. Ann Surg 2021; 273:876-881. [PMID: 31290763 DOI: 10.1097/sla.0000000000003449] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Single-center studies have demonstrated that resection of cavity shave margins (CSM) halves the rate of positive margins and re-excision in breast cancer patients undergoing partial mastectomy (PM). We sought to determine if these findings were externally generalizable across practice settings. METHODS In this multicenter randomized controlled trial occurring in 9 centers across the United States, stage 0-III breast cancer patients undergoing PM were randomly assigned to either have resection of CSM ("shave" group) or not ("no shave" group). Randomization occurred intraoperatively, after the surgeon had completed their standard PM. Primary outcome measures were positive margin and re-excision rates. RESULTS Between July 28, 2016 and April 13, 2018, 400 patients were enrolled in this trial. Four patients (2 in each arm) did not meet inclusion criteria after randomization, leaving 396 patients for analysis: 196 in the "shave" group and 200 to the "no shave" group. Median patient age was 65 years (range; 29-94). Groups were well matched at baseline for demographic and clinicopathologic factors. Prior to randomization, positive margin rates were similar in the "shave" and "no shave" groups (76/196 (38.8%) vs. 72/200 (36.0%), respectively, P = 0.604). After randomization, those in the "shave" group were significantly less likely than those in the "no shave" group to have positive margins (19/196 (9.7%) vs. 72/200 (36.0%), P < 0.001), and to require re-excision or mastectomy for margin clearance (17/196 (8.7%) vs. 47/200 (23.5%), P < 0.001). CONCLUSION Resection of CSM significantly reduces positive margin and re-excision rates in patients undergoing PM.
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Mohamedahmed AYY, Zaman S, Srinivasan A, Peterknecht E, Saeed S Mohammed S, AlBendary M, Alnzaer AA, Elsamani K. Do we need to routinely perform cavity shaving with breast-conserving surgery for breast cancer? A systematic review and meta-analysis. Surg Oncol 2020; 36:7-14. [PMID: 33271465 DOI: 10.1016/j.suronc.2020.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/30/2020] [Accepted: 11/15/2020] [Indexed: 11/29/2022]
Abstract
AIMS To evaluate comparative outcomes of breast-conserving surgery (BCS) of breast cancer with and without cavity shaving. METHODS A systematic search of multiple electronic data sources was conducted, and all randomised controlled trials (RCTs) comparing BCS with or without cavity shaving for breast cancer were included. Positive margin rate, second operation rate, operative time, post-operative haematoma, cosmetic appearance and budget cost were the evaluated outcome parameters for the meta-analysis. RESULTS Six RCTs reporting a total number of 971 patients; 495 of these underwent BCS plus shaving (BCS + S), and 473 underwent BCS alone were included. BCS + S showed significantly lower positive margin rate (Risk Ratio [RR] 0.40, P = 0.00001) and second operation rate (RR 0.38, P = 0.00001). BCS + S demonstrated longer operative time than BCS (79 ± 4 min vs 67 ± 3 min, Mean Difference 12.14, P = 0.002), and there was no significant difference in the risk of post-operative haematoma (RR 0.33, P = 0.20). CONCLUSION BCS + S is superior to BCS in terms of positive margins rate and second operation rate. Operative time is longer when cavity shaving is performed.
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Affiliation(s)
- Ali Yasen Y Mohamedahmed
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK.
| | - Shafquat Zaman
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Ananth Srinivasan
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Elizabeth Peterknecht
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | | | - Mohamed AlBendary
- Department of Anaesthesia, Sudan Medical Specialisation Board, Khartoum, Sudan
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9
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Partain N, Calvo C, Mokdad A, Colton A, Pouns K, Clifford E, Farr D, Huth J, Wooldridge R, Leitch AM. Differences in Re-excision Rates for Breast-Conserving Surgery Using Intraoperative 2D Versus 3D Tomosynthesis Specimen Radiograph. Ann Surg Oncol 2020; 27:4767-4776. [PMID: 32740738 DOI: 10.1245/s10434-020-08877-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 06/19/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Intraoperative specimen radiographs performed during breast conservation surgery for cancer reduces the need for re-excision for positive margins. We studied 2D versus 3D image-guided cavity margin excision and compared it to final pathology and need for additional surgery. METHODS We conducted a retrospective review of 657 breast-conserving operations performed for cancer from 2013 to 2018. Procedures were performed by four surgeons at a single tertiary institution with access intraoperatively to 2D and 3D radiographs. Data collected included demographics, intraoperative margin assessment, final pathology, and re-excision rates. RESULTS A total of 466 patients had 2D and 191 had 3D specimen imaging. The 2D group had a lower mean age and a higher body mass index and proportion of minority patients than the 3D group (P < 0.01). In the 3D group, there was a higher percentage of patients with mammographically denser breasts (P < 0.06); 58% of patients in the 3D group had additional imaging-directed cavity margins excised versus 32% of patients in the 2D group (P < 0.01). In the 2D group, 44 patients (9%) had positive final margins versus 8 patients (4%) in the 3D group (P = 0.02). No difference was found on total volume of excision (P = 0.56). The re-excision rate for the 2D group was 11% versus 5% for the 3D group (P = 0.02; adjusted odds ratio = 0.41, 95% confidence interval 0.19-0.86). CONCLUSIONS Re-excision rates using both modalities are low. A lower re-excision rate is independently associated with 3D tomosynthesis. This allows surgeons to excise additional margins at the index operation, decreasing reoperations and anxiety/costs for patients.
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Affiliation(s)
- Natalia Partain
- Division of Surgical Oncology, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Carissia Calvo
- Division of Surgical Oncology, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ali Mokdad
- Division of Surgical Oncology, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Andrea Colton
- Division of Surgical Oncology, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Katherine Pouns
- Division of Surgical Oncology, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Edward Clifford
- Division of Surgical Oncology, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Deborah Farr
- Division of Surgical Oncology, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - James Huth
- Division of Surgical Oncology, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rachel Wooldridge
- Division of Surgical Oncology, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - A Marilyn Leitch
- Division of Surgical Oncology, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
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10
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Nowikiewicz T, Śrutek E, Głowacka-Mrotek I, Tarkowska M, Żyromska A, Zegarski W. Clinical outcomes of an intraoperative surgical margin assessment using the fresh frozen section method in patients with invasive breast cancer undergoing breast-conserving surgery - a single center analysis. Sci Rep 2019; 9:13441. [PMID: 31530867 PMCID: PMC6748937 DOI: 10.1038/s41598-019-49951-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 08/30/2019] [Indexed: 11/10/2022] Open
Abstract
Breast conserving treatment (BCT) is a safe standard therapeutic method in patients with early invasive breast cancer. However, it is associated with an increased risk of residual neoplastic tissues in surgical margins. The aim of this study was to assess the outcome of the use of the intraoperative pathologic analysis by the frozen section (FS) method for evaluation of the extent of the primary lumpectomy. The study concerns a retrospective analysis of a group of 1102 patients who underwent BCT between Jan 2015 and Dec 2016. The assessment focused on the frequency of the intraoperative pathologic analysis of the primary lumpectomy extent (fresh frozen section method). The influence of the BCT specimen analysis method on the free margins width, as well as the rate and the cause of reoperation were evaluated. The intraoperative lumpectomy evaluation was performed in 45.8% (505/1102) of patients (Group I), while in the remaining 54.2% of the cases it was decided to abandon this procedure (Group II). Although in 72 (14.3%) patients the intraoperative analysis gave negative results, the margins contained residual tumor tissue (vs. 16.9% in Group II). In Group I, conversion from the previously planned BCT to mastectomy was necessary in 5.9% (30/505) patients (vs. 9.7% in Group II). The duration of surgery was 48.9 ± 17.3 minutes (Group I) and 42.9 ± 13.6 minutes (Group II). In patients undergoing BCT, the use of the intraoperative pathologic analysis by the FS method resulted in a reduction of the total number of reoperations performed due to residual tumor found in the margins following the primary lumpectomy. However, it statistically significantly extended the duration of the surgery.
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Affiliation(s)
- Tomasz Nowikiewicz
- Chair and Department of Surgical Oncology, Ludwik Rydygier's Collegium Medicum UMK in Bydgoszcz, Prof I. Romanowskiej 2, 85-796, Bydgoszcz, Poland. .,Department of Clinical Breast Cancer and Reconstructive Surgery, Oncology Centre-Prof. Franciszek Łukaszczyk Memorial Hospital, Prof I. Romanowskiej 2, 85-796, Bydgoszcz, Poland.
| | - Ewa Śrutek
- Chair and Department of Surgical Oncology, Ludwik Rydygier's Collegium Medicum UMK in Bydgoszcz, Prof I. Romanowskiej 2, 85-796, Bydgoszcz, Poland
| | - Iwona Głowacka-Mrotek
- Department of Rehabilitation, Ludwik Rydygier's Collegium Medicum UMK in Bydgoszcz, M. Sklodowskiej-Curie 9, 85-001, Bydgoszcz, Poland
| | - Magdalena Tarkowska
- Department of Laser Therapy and Physiotherapy, Ludwik Rydygier's Collegium Medicum UMK in Bydgoszcz, M. Sklodowskiej-Curie 9, 85-001, Bydgoszcz, Poland
| | - Agnieszka Żyromska
- Chair and Clinic of Oncology and Brachytherapy, Nicolaus Copernicus University Ludwik Rydygier Collegium Medicum in Bydgoszcz, Prof I. Romanowskiej 2, 85-796, Bydgoszcz, Poland.,Amethyst Radiotherapy Centre, Zgorzelec, Poland
| | - Wojciech Zegarski
- Chair and Department of Surgical Oncology, Ludwik Rydygier's Collegium Medicum UMK in Bydgoszcz, Prof I. Romanowskiej 2, 85-796, Bydgoszcz, Poland
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11
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van Lanschot CGF, Mast H, Hardillo JA, Monserez D, Ten Hove I, Barroso EM, Cals FLJ, Smits RWH, van der Kamp MF, Meeuwis CA, Sewnaik A, Verdijk R, van Leenders GJLH, Noordhoek Hegt V, Bakker Schut TC, Baatenburg de Jong RJ, Puppels GJ, Koljenović S. Relocation of inadequate resection margins in the wound bed during oral cavity oncological surgery: A feasibility study. Head Neck 2019; 41:2159-2166. [PMID: 30706624 PMCID: PMC6618026 DOI: 10.1002/hed.25690] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 12/31/2018] [Accepted: 01/10/2019] [Indexed: 11/10/2022] Open
Abstract
Background Specimen‐driven intraoperative assessment of the resection margins provides immediate feedback if an additional excision is needed. However, relocation of an inadequate margin in the wound bed has shown to be difficult. The objective of this study is to assess a reliable method for accurate relocation of inadequate tumor resection margins in the wound bed after intraoperative assessment of the specimen. Methods During oral cavity cancer surgery, the surgeon placed numbered tags on both sides of the resection line in a pair‐wise manner. After resection, one tag of each pair remained on the specimen and the other tag in the wound bed. Upon detection of an inadequate margin in the specimen, the tags were used to relocate this margin in the wound bed. Results The method was applied during 80 resections for oral cavity cancer. In 31 resections an inadequate margin was detected, and based on the paired tagging an accurate additional resection was achieved. Conclusion Paired tagging facilitates a reliable relocation of inadequate margins, enabling an accurate additional resection during the initial surgery.
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Affiliation(s)
- Cornelia G F van Lanschot
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Center for Optical Diagnostics and Therapy, Department of Dermatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Hetty Mast
- Department of Oral and Maxillofacial surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jose A Hardillo
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dominiek Monserez
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ivo Ten Hove
- Center for Optical Diagnostics and Therapy, Department of Dermatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Oral and Maxillofacial surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Elisa M Barroso
- Center for Optical Diagnostics and Therapy, Department of Dermatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Pathology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Froukje L J Cals
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Center for Optical Diagnostics and Therapy, Department of Dermatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Roeland W H Smits
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Center for Optical Diagnostics and Therapy, Department of Dermatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Martine F van der Kamp
- Center for Optical Diagnostics and Therapy, Department of Dermatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Pathology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Cees A Meeuwis
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Aniel Sewnaik
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Rob Verdijk
- Department of Pathology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Geert J L H van Leenders
- Department of Pathology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Vincent Noordhoek Hegt
- Department of Pathology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Tom C Bakker Schut
- Center for Optical Diagnostics and Therapy, Department of Dermatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Robert J Baatenburg de Jong
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Gerwin J Puppels
- Center for Optical Diagnostics and Therapy, Department of Dermatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Senada Koljenović
- Center for Optical Diagnostics and Therapy, Department of Dermatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Pathology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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12
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Zhang X, Wang Y. A survey of current surgical treatment of early stage breast cancer in China. Oncoscience 2018; 5:239-247. [PMID: 30234145 PMCID: PMC6142897 DOI: 10.18632/oncoscience.445] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 03/22/2018] [Indexed: 02/06/2023] Open
Abstract
The purpose of this national survey is to explore the patterns of surgical management for early stage breast cancer patients in China. A paper questionnaire survey was sent to the representatives from 520 hospitals who attended an international symposium in Guangzhou, China, 2014. The questionnaire included demographic information, initials and most preferred approaches for breast cancer surgery. The results were presented descriptively. The response rate was 42.5%. Only 7% of hospitals with >50% rate of breast conserving surgery (BCS). Intraoperative frozen sections and additional cavity margins assessment were used at 88% and 30.9% of hospitals, respectively. For invasive carcinoma, 15% of participants defined an adequate margin as no tumor cells on the ink. Sentinel lymph node biopsy (SLNB) was routinely performed in 93.2% of hospitals. Only 16.6% of hospitals would embrace the conclusions of the American College of Surgeons Oncology Group (ACOSOG) Z0011 study and omit axillary lymph node dissection (ALND) for patients who fit the Z0011 criteria. The current patterns for the management of breast cancer patients are still lagging behind. Chinese doctors need to catch up with the updated results of the cutting-edge clinical studies and multiple measures are in need to improve this situation.
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Affiliation(s)
- Xin Zhang
- Department of Radiation Oncology, Chongqing University Cancer Hospital, Chongqing Cancer Institute, Chongqing Cancer Hospital, Chongqing, People’s Republic of China
| | - Ying Wang
- Department of Radiation Oncology, Chongqing University Cancer Hospital, Chongqing Cancer Institute, Chongqing Cancer Hospital, Chongqing, People’s Republic of China
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13
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Stelle L, Wellington J, Liang W, Buras R, Tafra L. Local-Regional Evaluation and Therapy: Maximizing Margin-Negative Breast Cancer Resection Rates on the First Try. CURRENT BREAST CANCER REPORTS 2018. [DOI: 10.1007/s12609-018-0273-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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14
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Guidi AJ, Tworek JA, Mais DD, Souers RJ, Blond BJ, Brown RW. Breast Specimen Processing and Reporting With an Emphasis on Margin Evaluation: A College of American Pathologists Survey of 866 Laboratories. Arch Pathol Lab Med 2018; 142:496-506. [PMID: 29328775 DOI: 10.5858/arpa.2016-0626-cp] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT - The College of American Pathologists (CAP) developed protocols for reporting pathologic characteristics of breast cancer specimens, including margin status. The Society of Surgical Oncology (SSO) and the American Society for Radiation Oncology (ASTRO) published treatment guidelines regarding margins in patients with invasive cancer; and SSO, ASTRO, and the American Society of Clinical Oncology (ASCO) recently published guidelines for patients with ductal carcinoma in situ. OBJECTIVE - To assess current practices among pathologists with regard to the processing/reporting of breast specimens, assess compliance with CAP cancer protocols, and assess alignment with SSO/ASTRO and SSO/ASTRO/ASCO guidelines. DESIGN - A survey concerning breast specimen processing/reporting was distributed to pathologists enrolled in the CAP Performance Improvement Program in Surgical Pathology. RESULTS - Ninety-four percent (716 of 764 respondents) and 91% (699 of 769 respondents) define positive margins as "tumor on ink" for invasive cancer and ductal carcinoma in situ, respectively, in compliance with CAP cancer protocols and with SSO/ASTRO and SSO/ASTRO/ASCO guidelines. Of 791 respondents who provided details regarding methods for margin evaluation, 608 (77%) exclusively examine perpendicular margins, facilitating guideline compliance. However, 183 of 791 respondents (23%) examine en face margins in at least a subset of specimens, which may preclude guideline compliance in some cases. When separate cavity (shave) margins are examined, while 517 of 586 respondents (88%) ink these specimens, 69 of 586 (12%) do not, and this may also preclude guideline compliance in some cases. CONCLUSIONS - A substantial proportion of survey participants report margin status for breast cancer specimens in a manner consistent with CAP cancer protocols, and in alignment with SSO/ASTRO and SSO/ASTRO/ASCO guidelines. However, there are opportunities for some laboratories to modify procedures in order to facilitate more complete adherence to guidelines.
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Affiliation(s)
| | | | | | | | | | - Richard W Brown
- From the Department of Pathology, Newton-Wellesley Hospital, Newton, Massachusetts (Dr Guidi); the Department of Pathology, St. Joseph Mercy Hospital, Ann Arbor, Michigan (Dr Tworek); the Department of Pathology, University of Texas Health Sciences Center University Hospital, San Antonio (Dr Mais); Biostatistics (Ms Souers) and Surveys - Cytopathology (Ms Blond), College of American Pathologists, Northfield, Illinois; and the Department of Pathology, Memorial Hermann Southwest Hospital, Houston, Texas (Dr Brown)
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15
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Reyna C, DeSnyder SM. Intraoperative Margin Assessment in Breast Cancer Management. Surg Oncol Clin N Am 2018; 27:155-165. [DOI: 10.1016/j.soc.2017.08.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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16
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Low rate of positive margins and re-excision after partial mastectomy in highly selected breast cancer patients: A Chinese single-institution experience. Oncotarget 2017; 8:12225-12233. [PMID: 28103572 PMCID: PMC5355339 DOI: 10.18632/oncotarget.14686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [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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17
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Bouzaiene H, Triki A, Ghalleb M, Chemlali M, Benzarti Z, Ben Hassouna J, Gammoudi A, Rahal K. Is the systematic circumferential tumor cavity shaving a representative sample for the remaining mammary gland? About 75 cases. Breast 2017. [PMID: 28644994 DOI: 10.1016/j.breast.2017.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION The conservative surgery is more and more indicated for breast cancer. However, we still fear local recurrence which is mostly due to residual tumors?. Several techniques have been used to minimize theses residual tumors; one of them is the systematic circumferential tumor cavity shaving (SCTCS). METHODS We sampled 75 female patients who had conservative surgery with positive shaved margins in the anatomopathology examination and to whom a complementary treatment with mastectomy have been decided. RESULTS The median age was 48 years old. The median tumor size was 23 mm. In the histological examination of the tumors, 93% were invasive ductal carcinoma associated in 50% of the cases to the presence of ductal carcinoma in situ (DCIS) where all the lumpectomies had clear margin. For the SCTCS, 62,2% were DCIS and in 17,6% of the cases were invasive ductal carcinoma. A complementary treatment with mastectomy was indicated to all the patients. A residual tumor was detected in the remaining mammary gland in 47,7% of the cases out of which 50% were DCIS. Local recurrence happened in three patients (4,6%) after a median of follow up of 36 months. The overall survival and the disease free survival at five years were respectively 83,6% and 75,5%. CONCLUSION Standardized lumpectomy cavity shaving provides a backup to lumpectomy margins in conservative breast surgery but it can also be used as a sample for the remaining breast, helping to detect the residual tumor, and decreasing the rates of local recurrence after BCT.
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Affiliation(s)
- H Bouzaiene
- Surgical Oncology Department, Institute Salah Azeiz of Oncology, Tunis, Tunisia
| | - A Triki
- Surgical Oncology Department, Institute Salah Azeiz of Oncology, Tunis, Tunisia
| | - M Ghalleb
- Surgical Oncology Department, Institute Salah Azeiz of Oncology, Tunis, Tunisia.
| | - M Chemlali
- Surgical Oncology Department, Institute Salah Azeiz of Oncology, Tunis, Tunisia
| | - Z Benzarti
- Surgical Oncology Department, Institute Salah Azeiz of Oncology, Tunis, Tunisia
| | - J Ben Hassouna
- Surgical Oncology Department, Institute Salah Azeiz of Oncology, Tunis, Tunisia
| | - A Gammoudi
- Anatomopathology Department, Institute Salah Azeiz of Oncology, Tunis, Tunisia
| | - K Rahal
- Surgical Oncology Department, Institute Salah Azeiz of Oncology, Tunis, Tunisia
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18
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Corsi F, Sorrentino L, Bonzini M, Bossi D, Truffi M, Amadori R, Nebuloni M, Brillat B, Mazzucchelli S. Cavity Shaving Reduces Involved Margins and Reinterventions Without Increasing Costs in Breast-Conserving Surgery: A Propensity Score-Matched Study. Ann Surg Oncol 2017; 24:1516-1524. [DOI: 10.1245/s10434-017-5774-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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19
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Gray RJ, Pockaj BA, Garvey E, Blair S. Intraoperative Margin Management in Breast-Conserving Surgery: A Systematic Review of the Literature. Ann Surg Oncol 2017; 25:18-27. [PMID: 28058560 DOI: 10.1245/s10434-016-5756-4] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Indexed: 01/12/2023]
Abstract
BACKGROUND Breast surgeons have a wide variety of intraoperative techniques available to help achieve low rates for positive margins of excision, with variable levels of evidence. METHODS A systematic review of the medical literature from 1995 to July 2016 was conducted, with 434 abstracts identified and evaluated. The analysis included 106 papers focused on intraoperative management of breast cancer margins and contained actionable data. RESULTS Ultrasound-guided lumpectomy for palpable tumors, as an alternative to palpation guidance, can lower positive margin rates, but the effect when used as an alternative to wire localization (WL) for nonpalpable tumors is less certain. Localization techniques such as radioactive seed localization and radioguided occult lesion localization were found potentially to lower positive margin rates as alternatives to WL depending on baseline positive margin rates. Intraoperative pathologic methods including gross histology, frozen section analysis, and imprint cytology all have the potential to lower the rates of positive margins. Cavity-shave margins and the Marginprobe device both lower rates of positive margins, with some potential for negative cosmetic effects. Specimen radiography and multiple miscellaneous techniques did not affect positive margin rates or provided too little evidence for formation of a conclusion. CONCLUSIONS A systematic review of the literature showed evidence that several intraoperative techniques and actions can lower the rates of positive margins. These results are presented together with graded recommendations.
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Affiliation(s)
| | | | - Erin Garvey
- Department of Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Sarah Blair
- UCSD Department of Surgery, UCSD Cancer Center, Encinitas, USA
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20
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Lebya K, Garcia‐Smith R, Swaminathan R, Jones A, Russell J, Joste N, Bisoffi M, Trujillo K. Towards a personalized surgical margin for breast conserving surgery—Implications of field cancerization in local recurrence. J Surg Oncol 2017; 115:109-115. [DOI: 10.1002/jso.24469] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 09/19/2016] [Indexed: 01/21/2023]
Affiliation(s)
- Katarina Lebya
- Department of Cell Biology and PhysiologyUniversity of New Mexico Health Sciences CenterAlbuquerqueNew Mexico
| | - Randi Garcia‐Smith
- Department of Cell Biology and PhysiologyUniversity of New Mexico Health Sciences CenterAlbuquerqueNew Mexico
| | | | - Anna Jones
- Department of Internal MedicineUniversity of New Mexico Health Science CenterAlbuquerqueNew Mexico
| | - John Russell
- Department of SurgeryUniversity of New Mexico Health Science CenterAlbuquerqueNew Mexico
| | - Nancy Joste
- Department of PathologyUniversity of New Mexico Health Science CenterAlbuquerqueNew Mexico
| | - Marco Bisoffi
- Biochemistry and Molecular BiologySchmid College of Science and Technology Chapman UniversityOrangeCalifornia
| | - Kristina Trujillo
- Department of Cell Biology and PhysiologyUniversity of New Mexico Health Sciences CenterAlbuquerqueNew Mexico
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21
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Cavity Shaving plus Lumpectomy versus Lumpectomy Alone for Patients with Breast Cancer Undergoing Breast-Conserving Surgery: A Systematic Review and Meta-Analysis. PLoS One 2017; 12:e0168705. [PMID: 28046058 PMCID: PMC5207394 DOI: 10.1371/journal.pone.0168705] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 12/04/2016] [Indexed: 12/11/2022] Open
Abstract
The margin status is a well-established prognostic predictor for patients undergoing breast-conserving surgery (BCS). Recent data suggested that cavity shaving in addition to lumpectomy might be a promising approach for improving the clinical outcomes. We aimed to compare the efficacy and safety between cavity shaving plus lumpectomy and lumpectomy alone with a systematic review and meta-analysis. We searched the PubMed, Embase, and Cochrane CENTRAL databases for studies comparing cavity shaving with lumpectomy before June 10, 2016. Both comparative studies and self-control studies were included. A random-effects model was used to estimate the odds ratios (ORs) for positive margin rate, reoperation rate, recurrence rate, and weighted mean difference (WMD) for excised tissue volume. Twenty-six studies were included in the meta-analysis. The cavity shaving group had a significantly lower positive margin rate than the BCS-alone group (16.4% vs. 31.9%; OR = 0.41, 95% CI 0.32-0.53, P < 0.05). Cavity shaving was associated with a significantly decreased rate of reoperation (OR = 0.42, 95% CI 0.30-0.59, P < 0.05). The overall locoregional rate was low for cavity shaving and BCS-alone (3% vs. 4%). Cavity shaving had no significant effect on the risk of locoregional recurrence (OR = 0.86, 95% CI 0.32-2.35; P = 0.78). The excised tissue volume did not differ substantially between cavity shaving and BCS alone (WMD = -23.88, 95% CI -55.20 to 7.44, P = 0.14). For patients undergoing BCS, additional cavity shaving was an effective method to decrease the positive margin rate and avoid reoperation. The addition of cavity shaving did not appear to have excessive excised tissue volume compared with partial mastectomy alone.
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22
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Pata G, Bartoli M, Bianchi A, Pasini M, Roncali S, Ragni F. Additional Cavity Shaving at the Time of Breast-Conserving Surgery Enhances Accuracy of Margin Status Examination. Ann Surg Oncol 2016; 23:2802-2808. [DOI: 10.1245/s10434-016-5210-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Volders JH, Haloua MH, Krekel NMA, Meijer S, van den Tol PM. Current status of ultrasound-guided surgery in the treatment of breast cancer. World J Clin Oncol 2016; 7:44-53. [PMID: 26862490 PMCID: PMC4734937 DOI: 10.5306/wjco.v7.i1.44] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 09/02/2015] [Accepted: 10/27/2015] [Indexed: 02/06/2023] Open
Abstract
The primary goal of breast-conserving surgery (BCS) is to obtain tumour-free resection margins. Margins positive or focally positive for tumour cells are associated with a high risk of local recurrence, and in the case of tumour-positive margins, re-excision or even mastectomy are sometimes needed to achieve definite clear margins. Unfortunately, tumour-involved margins and re-excisions after lumpectomy are still reported in up to 40% of patients and additionally, unnecessary large excision volumes are described. A secondary goal of BCS is the cosmetic outcome and one of the main determinants of worse cosmetic outcome is a large excision volume. Up to 30% of unsatisfied cosmetic outcome is reported. Therefore, the search for better surgical techniques to improve margin status, excision volume and consequently, cosmetic outcome has continued. Nowadays, the most commonly used localization methods for BCS of non-palpable breast cancers are wire-guided localization (WGL) and radio-guided localization (RGL). WGL and RGL are invasive procedures that need to be performed pre-operatively with technical and scheduling difficulties. For palpable breast cancer, tumour excision is usually guided by tactile skills of the surgeon performing “blind” surgery. One of the surgical techniques pursuing the aims of radicality and small excision volumes includes intra-operative ultrasound (IOUS). The best evidence available demonstrates benefits of IOUS with a significantly high proportion of negative margins compared with other localization techniques in palpable and non-palpable breast cancer. Additionally, IOUS is non-invasive, easy to learn and can centralize the tumour in the excised specimen with low amount of healthy breast tissue being excised. This could lead to better cosmetic results of BCS. Despite the advantages of IOUS, only a small amount of surgeons are performing this technique. This review aims to highlight the position of ultrasound-guided surgery for malignant breast tumours in the search for better oncological and cosmetic outcomes.
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Edwards SB, Leitman IM, Wengrofsky AJ, Giddins MJ, Harris E, Mills CB, Fukuhara S, Cassaro S. Identifying Factors and Techniques to Decrease the Positive Margin Rate in Partial Mastectomies: Have We Missed the Mark? Breast J 2016; 22:303-9. [DOI: 10.1111/tbj.12573] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Sara B. Edwards
- Department of Surgery; Mount Sinai Beth Israel; Icahn School of Medicine at Mount Sinai; New York New York
| | - I. Michael Leitman
- Department of Surgery; Mount Sinai Beth Israel; Icahn School of Medicine at Mount Sinai; New York New York
| | - Aaron J. Wengrofsky
- Department of Surgery; Mount Sinai Beth Israel; Icahn School of Medicine at Mount Sinai; New York New York
| | - Marley. J. Giddins
- Department of Surgery; Mount Sinai Beth Israel; Icahn School of Medicine at Mount Sinai; New York New York
| | - Emily Harris
- Department of Surgery; Mount Sinai Beth Israel; Icahn School of Medicine at Mount Sinai; New York New York
| | - Christopher B. Mills
- Department of Surgery; Mount Sinai Beth Israel; Icahn School of Medicine at Mount Sinai; New York New York
| | - Shinichi Fukuhara
- Department of Surgery; Mount Sinai Beth Israel; Icahn School of Medicine at Mount Sinai; New York New York
| | - Sebastiano Cassaro
- Department of Surgery; Mount Sinai Beth Israel; Icahn School of Medicine at Mount Sinai; New York New York
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Landercasper J, Attai D, Atisha D, Beitsch P, Bosserman L, Boughey J, Carter J, Edge S, Feldman S, Froman J, Greenberg C, Kaufman C, Morrow M, Pockaj B, Silverstein M, Solin L, Staley A, Vicini F, Wilke L, Yang W, Cody H. Toolbox to Reduce Lumpectomy Reoperations and Improve Cosmetic Outcome in Breast Cancer Patients: The American Society of Breast Surgeons Consensus Conference. Ann Surg Oncol 2015; 22:3174-83. [PMID: 26215198 PMCID: PMC4550635 DOI: 10.1245/s10434-015-4759-x] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Indexed: 12/29/2022]
Abstract
BACKGROUND Multiple recent reports have documented significant variability of reoperation rates after initial lumpectomy for breast cancer. To address this issue, a multidisciplinary consensus conference was convened during the American Society of Breast Surgeons 2015 annual meeting. METHODS The conference mission statement was to "reduce the national reoperation rate in patients undergoing breast conserving surgery for cancer, without increasing mastectomy rates or adversely affecting cosmetic outcome, thereby improving value of care." The goal was to develop a toolbox of recommendations to reduce the variability of reoperation rates and improve cosmetic outcomes. Conference participants included providers from multiple disciplines involved with breast cancer care, as well as a patient representative. Updated systematic reviews of the literature and invited presentations were sent to participants in advance. After topic presentations, voting occurred for choice of tools, level of evidence, and strength of recommendation. RESULTS The following tools were recommended with varied levels of evidence and strength of recommendation: compliance with the SSO-ASTRO Margin Guideline; needle biopsy for diagnosis before surgical excision of breast cancer; full-field digital diagnostic mammography with ultrasound as needed; use of oncoplastic techniques; image-guided lesion localization; specimen imaging for nonpalpable cancers; use of specialized techniques for intraoperative management, including excisional cavity shave biopsies and intraoperative pathology assessment; formal pre- and postoperative planning strategies; and patient-reported outcome measurement. CONCLUSIONS A practical approach to performance improvement was used by the American Society of Breast Surgeons to create a toolbox of options to reduce lumpectomy reoperations and improve cosmetic outcomes.
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Affiliation(s)
- Jeffrey Landercasper
- Gundersen Health System Norma J. Vinger Center for Breast Care, La Crosse, WI, USA,
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26
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Chagpar AB, Killelea BK, Tsangaris TN, Butler M, Stavris K, Li F, Yao X, Bossuyt V, Harigopal M, Lannin DR, Pusztai L, Horowitz NR. A Randomized, Controlled Trial of Cavity Shave Margins in Breast Cancer. N Engl J Med 2015; 373:503-10. [PMID: 26028131 PMCID: PMC5584380 DOI: 10.1056/nejmoa1504473] [Citation(s) in RCA: 261] [Impact Index Per Article: 26.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Routine resection of cavity shave margins (additional tissue circumferentially around the cavity left by partial mastectomy) may reduce the rates of positive margins (margins positive for tumor) and reexcision among patients undergoing partial mastectomy for breast cancer. METHODS In this randomized, controlled trial, we assigned, in a 1:1 ratio, 235 patients with breast cancer of stage 0 to III who were undergoing partial mastectomy, with or without resection of selective margins, to have further cavity shave margins resected (shave group) or not to have further cavity shave margins resected (no-shave group). Randomization occurred intraoperatively after surgeons had completed standard partial mastectomy. Positive margins were defined as tumor touching the edge of the specimen that was removed in the case of invasive cancer and tumor that was within 1 mm of the edge of the specimen removed in the case of ductal carcinoma in situ. The rate of positive margins was the primary outcome measure; secondary outcome measures included cosmesis and the volume of tissue resected. RESULTS The median age of the patients was 61 years (range, 33 to 94). On final pathological testing, 54 patients (23%) had invasive cancer, 45 (19%) had ductal carcinoma in situ, and 125 (53%) had both; 11 patients had no further disease. The median size of the tumor in the greatest diameter was 1.1 cm (range, 0 to 6.5) in patients with invasive carcinoma and 1.0 cm (range, 0 to 9.3) in patients with ductal carcinoma in situ. Groups were well matched at baseline with respect to demographic and clinicopathological characteristics. The rate of positive margins after partial mastectomy (before randomization) was similar in the shave group and the no-shave group (36% and 34%, respectively; P=0.69). After randomization, patients in the shave group had a significantly lower rate of positive margins than did those in the no-shave group (19% vs. 34%, P=0.01), as well as a lower rate of second surgery for margin clearance (10% vs. 21%, P=0.02). There was no significant difference in complications between the two groups. CONCLUSIONS Cavity shaving halved the rates of positive margins and reexcision among patients with partial mastectomy. (Funded by the Yale Cancer Center; ClinicalTrials.gov number, NCT01452399.).
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Lobular/pathology
- Carcinoma, Lobular/surgery
- Female
- Humans
- Mastectomy, Segmental/methods
- Middle Aged
- Neoplasm Invasiveness
- Neoplasm Staging
- Reoperation
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Affiliation(s)
- Anees B Chagpar
- From the Departments of Surgery (A.B.C., B.K.K., M.B., K.S., D.R.L., N.R.H.), Pathology (V.B., M.H.), and Medicine (L.P.), Yale Cancer Center (A.B.C., B.K.K., M.B., K.S., F.L., X.Y., D.R.L., L.P., N.R.H.), and Yale Center for Analytical Sciences (F.L., X.Y.), Yale University School of Medicine, New Haven, CT; and the Department of Surgery, Thomas Jefferson University, Philadelphia (T.N.T.)
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Harness JK, Giuliano AE, Pockaj BA, Downs-Kelly E. Margins: A Status Report from the Annual Meeting of the American Society of Breast Surgeons. Ann Surg Oncol 2014; 21:3192-7. [DOI: 10.1245/s10434-014-3957-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Indexed: 01/04/2023]
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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: 2.4] [Reference Citation Analysis] [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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