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Wernly D, Beniere C, Besse V, Seidler S, Lachat R, Letovanec I, Huber D, Simonson C. SENOSI Confocal Microscopy: A New and Innovating Way to Detect Positive Margins in Non-Palpable Breast Cancer? Life (Basel) 2024; 14:204. [PMID: 38398713 PMCID: PMC10890637 DOI: 10.3390/life14020204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/20/2024] [Accepted: 01/24/2024] [Indexed: 02/25/2024] Open
Abstract
In Switzerland, breast cancer is the leading cancer among women, with breast-conserving surgery (BCS) being the preferred treatment for small tumors. The margin status post-surgery is a critical predictor of local recurrence. Achieving negative margins remains a challenge, leading to re-excision in 20-30% of cases. Traditional methods like intraoperative examination palpation and radiography have limitations in assessing excised margins. This study introduces the Histolog® Scanner, a confocal microscopy tool, as a potential solution. It provides real-time images of tissue architecture, allowing for rapid and accurate assessment of excised margins. Our research compared the Histolog® Scanner with standard per-operative radiography in patients with non palpable breast cancer. Preliminary results indicate that the Histolog® Scanner offers a reliable and time-efficient method for margin assessment, suggesting its potential for clinical integration.
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Affiliation(s)
- Deborah Wernly
- Hôpital du Valais, 1951 Sion, Switzerland; (C.B.); (V.B.); (S.S.); (R.L.); (I.L.); (D.H.); (C.S.)
- Centre Hospitalier Universitaire Vaudois (CHUV), 1011 Lausanne, Switzerland
| | - Charles Beniere
- Hôpital du Valais, 1951 Sion, Switzerland; (C.B.); (V.B.); (S.S.); (R.L.); (I.L.); (D.H.); (C.S.)
- Aurigen, Centre de Pathologie, 1004 Lausanne, Switzerland
| | - Valerie Besse
- Hôpital du Valais, 1951 Sion, Switzerland; (C.B.); (V.B.); (S.S.); (R.L.); (I.L.); (D.H.); (C.S.)
| | - Stephanie Seidler
- Hôpital du Valais, 1951 Sion, Switzerland; (C.B.); (V.B.); (S.S.); (R.L.); (I.L.); (D.H.); (C.S.)
| | - Regine Lachat
- Hôpital du Valais, 1951 Sion, Switzerland; (C.B.); (V.B.); (S.S.); (R.L.); (I.L.); (D.H.); (C.S.)
| | - Igor Letovanec
- Hôpital du Valais, 1951 Sion, Switzerland; (C.B.); (V.B.); (S.S.); (R.L.); (I.L.); (D.H.); (C.S.)
| | - Daniela Huber
- Hôpital du Valais, 1951 Sion, Switzerland; (C.B.); (V.B.); (S.S.); (R.L.); (I.L.); (D.H.); (C.S.)
- Department of Pediatrics, Gynecology and Obstetrics, Geneva University Hospitals, Boulevard de la Cluse 30, 1205 Geneva, Switzerland
| | - Colin Simonson
- Hôpital du Valais, 1951 Sion, Switzerland; (C.B.); (V.B.); (S.S.); (R.L.); (I.L.); (D.H.); (C.S.)
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Esgueva AJ, Sobrido C, Diaz-Botero S, Díez-Uriel E, Iscar T, De Miguel V, Regojo A, Rubio IT. Intraoperative ultrasound margin evaluation as a tool to reduce positive superficial margins in nipple and skin sparing mastectomy in breast cancer patients. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:107049. [PMID: 37660517 DOI: 10.1016/j.ejso.2023.107049] [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] [Received: 08/20/2023] [Accepted: 08/27/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Intraoperative ultrasound (IOUS) guided conservative surgery has been shown to reduce rates of positive margins in breast cancer. The aim of the study is to evaluate the feasibility of using IOUS to assess superficial/anterior margins in nipple and skin sparing mastectomy (NSM/SSM) and its impact on reducing rates of positive margins. METHODS This prospective study includes all breast cancer patients who had an indication for NSM/SSM at our Institution. Superficial margin width was measured by IOUS before surgery and the area marked on the skin. Same measurement was performed afterwards in the mastectomy specimen. Any superficial margin < 5 mm was re-excised intraoperatively following the mark on the skin. RESULTS Fifty-nine patients were included, 47 patients (79.7%) underwent NSM, and 12 patients (20.3%) a SSM. Of the 59 patients, 23 (38.98%) had margins ≥5 mm and 36 patients (61.02%) had margins of ≤5 mm. Of the 36 patients with superficial margins ≤5 mm, 20 had margins <2 mm, and 6 of them had intraoperative involved superficial margins in final pathology. However, after IOUS-guided re-excision, final pathology showed no involved margins. A 2 mm margin was set as the cut-off point for performing an intraoperative re-excision. IOUS guided re-excisions for intraoperative margins ≤2 mm significantly reduced the risk of close/positive margins in final pathology, p < 0.0001. CONCLUSION The results showed that IOUS margin evaluation significantly reduced the rate of superficial positive margins in NSM/SSM. It is feasible and effective and may avoid challenging reoperations and/or additional radiation therapy for positive margins.
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Affiliation(s)
- Antonio J Esgueva
- Department of Breast Surgical Oncology, Clinica Universidad de Navarra, Universidad de Navarra, Marquesado de Santa Marta 1, Madrid, 28027, Spain
| | - Carolina Sobrido
- Breast Imaging Unit, Department of Radiology, Clinica Universidad de Navarra, Universidad de Navarra, Marquesado de Santa Marta 1, Madrid, 28027, Spain
| | - Sebastián Diaz-Botero
- Department of Breast Surgical Oncology, Clinica Universidad de Navarra, Universidad de Navarra, Marquesado de Santa Marta 1, Madrid, 28027, Spain
| | - Elena Díez-Uriel
- Breast Imaging Unit, Department of Radiology, Clinica Universidad de Navarra, Universidad de Navarra, Marquesado de Santa Marta 1, Madrid, 28027, Spain
| | - Teresa Iscar
- Department of Pathology, Clinica Universidad de Navarra, Universidad de Navarra, Marquesado de Santa Marta 1, Madrid, 28027, Spain
| | - Virginia De Miguel
- Department of Nursing, Breast Surgical Oncology, Clinica Universidad de Navarra, Universidad de Navarra, Marquesado de Santa Marta 1, Madrid, 28027, Spain
| | - Ana Regojo
- Department of Nursing, Breast Surgical Oncology, Clinica Universidad de Navarra, Universidad de Navarra, Marquesado de Santa Marta 1, Madrid, 28027, Spain
| | - Isabel T Rubio
- Department of Breast Surgical Oncology, Clinica Universidad de Navarra, Universidad de Navarra, Marquesado de Santa Marta 1, Madrid, 28027, Spain.
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Fosko NK, Gribkova Y, Krupa K, Bs KJ, Moore D, Chen C, Potdevin L, Kumar S, Eladoumikdachi F, Kowzun MJ. The Use of Intraoperative Ultrasound During Breast Conserving Surgery. Clin Breast Cancer 2023; 23:54-59. [PMID: 36319507 DOI: 10.1016/j.clbc.2022.10.003] [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] [Received: 07/18/2022] [Accepted: 10/07/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVES The purpose of this study is to evaluate the utilization of intraoperative ultrasound (IOUS) for tumor localization in breast-conserving surgery and to examine its impact on margin positivity and re-excision rates. Additionally, the study seeks to identify factors contributing to surgeon utilization of IOUS. METHODS A retrospective chart review was conducted of patients with preoperative diagnosis of breast cancer undergoing breast-conserving surgery by breast surgeons at multiple centers within a single healthcare system. Characteristics such as lesion size, palpability, histology, receptor status, and use of neoadjuvant chemotherapy were recorded. Re-excision rates were determined based on localization technique and surgeons' status of breast ultrasound certification. RESULTS A total of 671 cases were performed, with 322 meeting study inclusion. 57 cases utilized IOUS, 250 utilized preoperative wire-guided localization (WGL), 10 used both methods and 5 cases used neither method. There was no significant difference in re-excision rates between IOUS and WGL or among the four surgeons. Ultrasound-certified surgeons were more likely to utilize IOUS, and re-excision rates trended higher for WGL, which may be clinically significant. CONCLUSION Increasing familiarity with and utilization of IOUS during breast-conserving surgery may be clinically advantageous over traditional localization techniques. Ultrasound certification may lead to increased use of IOUS among surgeons.
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Affiliation(s)
- Nicole K Fosko
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | | | - Kelly Krupa
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Kavita Jain Bs
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Dirk Moore
- Rutgers School of Public Health, New Brunswick, New Jersey
| | - Chunxia Chen
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Lindsay Potdevin
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Shicha Kumar
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | | | - Maria J Kowzun
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey.
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The Beneficial Impact of Intraoperative Ultrasound on Resection Margin Status during Breast Conserving Surgery. Int J Surg Oncol 2022; 2022:2268821. [DOI: 10.1155/2022/2268821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 11/05/2022] [Accepted: 11/23/2022] [Indexed: 12/12/2022] Open
Abstract
Background. Surgical resection with clear surgical cut margins is the mainstay of managing malignant breast neoplasms. Multiple techniques have been suggested to enhance resection status during breast-conserving surgery (BCS), including intraoperative ultrasonography (IOUS). Herein, we conducted the current investigation to reveal the benefit of IOUS on the achievement of R0 resection. Patients and Methods. This retrospective investigation included 140 patients who underwent BCS. They were divided into two groups: the IOUS group (40 cases) and the control group (100 cases). Our primary objective was to determine the free resection margin status (R0). Results. Both study groups expressed statistically comparable demographic and clinical data. Additionally, histopathological examination revealed no significant difference between the two groups regarding the tumor type, stage, or grade. Nonetheless, the R0 resection margin was more frequently encountered in association with IOUS application (97.5% compared to 79% in the control group), and that difference was statistically significant (
). Conclusion. The application of IOUS has a significant beneficial impact on the outcomes of BCS. It is associated with a marked decline in positive resection margins, and its application should be encouraged in the breast oncological practice.
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Sandor MF, Schwalbach B, Hofmann V, Istrate SE, Schuller Z, Ionescu E, Heimann S, Ragazzi M, Lux MP. Imaging of lumpectomy surface with large field-of-view confocal laser scanning microscope for intraoperative margin assessment - POLARHIS study. Breast 2022; 66:118-125. [PMID: 36240525 PMCID: PMC9574757 DOI: 10.1016/j.breast.2022.10.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 09/23/2022] [Accepted: 10/04/2022] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Breast-conserving surgery (BCS) in case of breast cancer and/or in-situ-carcinoma lesions (DCIS) intends to completely remove breast cancer while saving healthy tissue as much as possible to achieve better aesthetic and psychological outcomes for the patient. Such modality should result in postoperative tumor-free margins of the surgical resection in order to carry on with the next therapeutical steps of the patient care. However, 10-40% of patients undergo more than one procedure to achieve acceptable cancer-negative margins. A 2nd operation or further operation (re-operation) has physical, psychological, and economic consequences. It also delays the administration of adjuvant therapy, and has been associated with an elevated risk of local and distant disease relapse. In addition, a high re-operation rate can have significant economic effects - both for the service provider and for the payer. A more efficient intraoperative assessment of the margin may address these issues. Recently, a large field-of-view confocal laser scanning microscope designed to allow real-time intraoperative margin assessment has arrived on the market - the Histolog Scanner. In this paper, we present the first evaluation of lumpectomy margins assessment with this new device. MATERIALS AND METHODS 40 consecutive patients undergoing BCS with invasive and/or DCIS were included. The whole surface of the surgical specimens was imaged right after the operation using the Histolog Scanner (HLS). The assessment of all the specimen margins was performed intraoperatively according to the standard-of-care of the center which consists of combined ultrasound (IOUS) and/or conventional specimen radiography (CSR), and gross surgical inspection. Margin assessment on HLS images was blindly performed after the surgery by 5 surgeons and one pathologist. The capabilities to correctly determine margin status in HLS images was compared to the final histopathological assessment. Furthermore, the potential reduction of positive-margin and re-operation rates by utilization of the HLS were extrapolated. RESULTS The study population included 7/40 patients with DCIS (17.5%), 17/40 patients with DCIS and invasive ductal cancer (IDC NST) (42.5%), 10/40 patients with IDC NST (25%), 4/40 with invasive lobular cancer (ILC) (10%), and 1/40 patients with a mix of IDC NST, DCIS, and ILC. Clinical routine resulted in 13 patients with positive margins identified by final histopathological assessment, resulting in 12 re-operations (30% re-operation rate). Amongst these 12 patients, 10 had DCIS components involved in their margin, confirming the importance of improving the detection accuracy of this specific lesion. Surgeons, who were given a short familiarization on HLS images, and a pathologist were able to detect positive margins in 4/12 and 7/12 patients (33% and 58%), respectively, that were missed by the intraoperative standard of care. In addition, a retrospective analysis of the HLS images revealed that cancer lesions can be identified in 9/12 (75%) patients with positive margins. CONCLUSION The present study presents that breast cancer can be detected by surgeons and pathologists in HLS images of lumpectomy margins leading to a potential reduction of 30% and 75% of the re-operations. The Histolog Scanner is easily inserted into the clinical workflow and has the potential to improve the intraoperative standard-of-care for the assessment of breast conserving treatments. In addition, it has the potential to increase oncological safety and cosmetics by avoiding subsequent resections and can also have a significant positive economic effect for service providers and cost bearers. The data presented in this study will have to be further confirmed in a prospective phase-III-trial.
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MESH Headings
- Female
- Humans
- Breast Neoplasms/diagnostic imaging
- Breast Neoplasms/surgery
- Breast Neoplasms/pathology
- Carcinoma, Ductal, Breast/diagnostic imaging
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Intraductal, Noninfiltrating/diagnostic imaging
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Lasers
- Margins of Excision
- Mastectomy, Segmental/methods
- Neoplasm Recurrence, Local/pathology
- Prospective Studies
- Reoperation
- Retrospective Studies
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Affiliation(s)
- Mariana-Felicia Sandor
- Department of Gynecology and Obstetrics, Women's Hospital St. Louise, Paderborn, Women's Hospital, St. Josefs, Salzkotten, St. Vincenz-Krankenhaus GmbH, Husener Str. 81, 33098, Paderborn, Germany
| | - Beatrice Schwalbach
- Department of Gynecology and Obstetrics, Women's Hospital St. Louise, Paderborn, Women's Hospital, St. Josefs, Salzkotten, St. Vincenz-Krankenhaus GmbH, Husener Str. 81, 33098, Paderborn, Germany
| | - Viktoria Hofmann
- Department of Gynecology and Obstetrics, Women's Hospital St. Louise, Paderborn, Women's Hospital, St. Josefs, Salzkotten, St. Vincenz-Krankenhaus GmbH, Husener Str. 81, 33098, Paderborn, Germany
| | - Simona-Elena Istrate
- Department of Gynecology and Obstetrics, Women's Hospital St. Louise, Paderborn, Women's Hospital, St. Josefs, Salzkotten, St. Vincenz-Krankenhaus GmbH, Husener Str. 81, 33098, Paderborn, Germany
| | - Zlatna Schuller
- Department of Gynecology and Obstetrics, Women's Hospital St. Louise, Paderborn, Women's Hospital, St. Josefs, Salzkotten, St. Vincenz-Krankenhaus GmbH, Husener Str. 81, 33098, Paderborn, Germany
| | - Elena Ionescu
- Department of Gynecology and Obstetrics, Women's Hospital St. Louise, Paderborn, Women's Hospital, St. Josefs, Salzkotten, St. Vincenz-Krankenhaus GmbH, Husener Str. 81, 33098, Paderborn, Germany
| | - Sara Heimann
- Department of Gynecology and Obstetrics, Women's Hospital St. Louise, Paderborn, Women's Hospital, St. Josefs, Salzkotten, St. Vincenz-Krankenhaus GmbH, Husener Str. 81, 33098, Paderborn, Germany
| | - Moira Ragazzi
- Pathology Unit, Azienda USL - IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Michael P Lux
- Department of Gynecology and Obstetrics, Women's Hospital St. Louise, Paderborn, Women's Hospital, St. Josefs, Salzkotten, St. Vincenz-Krankenhaus GmbH, Husener Str. 81, 33098, Paderborn, Germany.
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Bader W, Vogel-Minea CM, Blohmer JU, Duda V, Eichler C, Fallenberg E, Farrokh A, Golatta M, Gruber I, Hackelöer BJ, Heil J, Madjar H, Marzotko E, Merz E, Müller-Schimpfle M, Mundinger A, Ohlinger R, Peisker U, Schäfer FKW, Schulz-Wendtland R, Solbach C, Warm M, Watermann D, Wojcinski S, Hahn M. Best Practice Guideline - DEGUM Recommendations on Breast Ultrasound. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2022; 43:570-582. [PMID: 34921376 DOI: 10.1055/a-1634-5021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
For many years, breast ultrasound has been used in addition to mammography as an important method for clarifying breast findings. However, differences in the interpretation of findings continue to be problematic 1 2. These differences decrease the diagnostic accuracy of ultrasound after detection of a finding and complicate interdisciplinary communication and the comparison of scientific studies 3. In 1999, the American College of Radiology (ACR) created a working group (International Expert Working Group) that developed a classification system for ultrasound examinations based on the established BI-RADS classification of mammographic findings under consideration of literature data 4. Due to differences in content, the German Society for Ultrasound in Medicine (DEGUM) published its own BI-RADS-analogue criteria catalog in 2006 3. In addition to the persistence of differences in content, there is also an issue with formal licensing with the current 5th edition of the ACR BI-RADS catalog, even though the content is recognized by the DEGUM as another system for describing and documenting findings. The goal of the Best Practice Guideline of the Breast Ultrasound Working Group of the DEGUM is to provide colleagues specialized in senology with a current catalog of ultrasound criteria and assessment categories as well as best practice recommendations for the various ultrasound modalities.
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Affiliation(s)
- Werner Bader
- Zentrum für Frauenheilkunde, Brustzentrum, Universitätsklinikum OWL Bielefeld, Germany
| | - Claudia Maria Vogel-Minea
- Brustzentrum, Diagnostische und Interventionelle Senologie, Rottal-Inn-Kliniken Eggenfelden, Germany
| | - Jens-Uwe Blohmer
- Klinik für Gynäkologie mit Brustzentrum, Charité-Universitätsmedizin Berlin, Germany
| | - Volker Duda
- Senologische Diagnostik, Universitätsklinikum Gießen und Marburg, Germany
| | | | - Eva Fallenberg
- Brustzentrum, Diagnostische und Interventionelle Senologie, LMU Klinikum der Universität München Medizinische Klinik und Poliklinik IV, München, Germany
| | - André Farrokh
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein Campus Kiel, Germany
| | - Michael Golatta
- Sektion Senologie, Universitäts-Frauenklinik Heidelberg, Germany
| | - Ines Gruber
- Department für Frauengesundheit, Universitätsfrauenklinikum Tübingen, Germany
| | | | - Jörg Heil
- Sektion Senologie, Universitäts-Frauenklinik Heidelberg, Germany
| | - Helmut Madjar
- Gynäkologie und Senologie Wiesbaden, Praxis, Wiesbaden, Germany
| | - Ellen Marzotko
- Mammadiagnostik, Frauenheilkunde und Geburtshilfe, Praxis, Erfurt, Germany
| | - Eberhard Merz
- Ultraschall und Pränatalmedizin Frankfurt, Zentrum, Frankfurt/Main, Germany
| | - Markus Müller-Schimpfle
- DKG-Brustzentrum, Klinik für Radiologie, Neuroradiologie und Nuklearmedizin Frankfurt, Frankfurt am Main, Germany
| | - Alexander Mundinger
- Brustzentrum Osnabrück - Bildgebende und interventionelle Mamma Diagnostik, Franziskus Hospital Harderberg, Niels-Stensen-Kliniken, Georgsmarienhütte, Germany
| | - Ralf Ohlinger
- Interdisziplinäres Brustzentrum, Universitätsmedizin Greifswald, Klinik für Frauenheilkunde und Geburtshilfe, Greifswald, Germany
| | - Uwe Peisker
- BrustCentrum Aachen-Kreis Heinsberg, Hermann-Josef-Krankenhaus, Akademisches Lehrkrankenhaus der RWTH Aachen, Erkelenz, Germany
| | - Fritz K W Schäfer
- Bereich Mammadiagnostik und Interventionen, Universitätsklinikum Schleswig-Holstein Campus Kiel, Germany
| | | | - Christine Solbach
- Senologie, Klinik für Frauenheilkunde und Geburtshilfe, Universitätsklinikum Frankfurt, Germany
| | - Mathias Warm
- Brustzentrum, Krankenhaus Holweide, Kliniken der Stadt Köln, Köln, Germany
| | - Dirk Watermann
- Frauenklinik, Evangelisches Diakoniekrankenhaus, Freiburg, Germany
| | - Sebastian Wojcinski
- Zentrum für Frauenheilkunde, Brustzentrum, Universitätsklinikum OWL Bielefeld, Germany
| | - Markus Hahn
- Department für Frauengesundheit, Universitätsfrauenklinikum Tübingen, Germany
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Manhoobi IP, Bodilsen A, Nijkamp J, Pareek A, Tramm T, Redsted S, Christiansen P. Diagnostic accuracy of radiography, digital breast tomosynthesis, micro-CT and ultrasound for margin assessment during breast surgery: A systematic review and meta-analysis. Acad Radiol 2022; 29:1560-1572. [PMID: 34996687 DOI: 10.1016/j.acra.2021.12.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/29/2021] [Accepted: 12/06/2021] [Indexed: 12/14/2022]
Abstract
RATIONALE AND OBJECTIVES Achieving adequate resection margins in breast conserving surgery is challenging and often demands more than one surgical procedure. We evaluated pooled diagnostic sensitivity, and specificity of radiological methods for intraoperative margin assessment and their impact on repeat surgery rate. MATERIALS AND METHODS We included studies using radiography, digital breast tomosynthesis (DBT), micro-CT, and ultrasound for intraoperative margin assessment with the histological assessment as the reference method. A systematic search was performed in PubMed, Embase, Cochrane Library, Scopus, and Web of Science. Two investigators screened the studies for eligibility criteria and extracted data of the included studies independently. The quality assessment on diagnostic accuracy studies (QUADAS)-2 tool was used. A bivariate random effect model was used to obtained pooled sensitivity and specificity of the index tests in the meta-analysis. RESULTS The systematic search resulted in screening of 798 unique records. Twenty-two articles with 29 radiological imaging methods were selected for meta-analysis. Pooled sensitivity and specificity and area under the curve were calculated for each of the 4 subgroups in the meta-analysis respectively: Radiography; 52%, 77%, 60%, DBT; 67%, 76%, 76%, micro-CT; 68%, 69%, 72%, and ultrasound; 72%, 78%, 80%. The repeat surgery rate was poorly reported in the included studies. CONCLUSION Ultrasound showed the highest and radiography the lowest diagnostic performance for intraoperative margin assessment. However, the heterogeneity between studies was high and the subgroups small. The radiological methods for margin assessment need further improvement to provide reliable guidance in the clinical workflow and to prevent repeat surgeries.
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Affiliation(s)
| | - Anne Bodilsen
- Department of Abdominal Surgery (A.B.), Aarhus University Hospital, Denmark
| | - Jasper Nijkamp
- Danish center for Particle Therapy (J.N.), Aarhus University Hospital, Department of Clinical Medicine, Aarhus University, Denmark
| | - Anuj Pareek
- Department of Radiology (A.P.), North Zealand Hospital, Denmark
| | - Trine Tramm
- Department of Pathology (T.T.), Aarhus University Hospital, Denmark
| | - Søren Redsted
- Department of Radiology, (I.P.M., S.R.), Aarhus University Hospital, Denmark
| | - Peer Christiansen
- Department of Plastic and Breast Surgery (P.C.), Aarhus University Hospital, Denmark
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Walker E, Linders DGJ, Abenojar E, Wang X, Hazelbag HM, Straver ME, Bijlstra OD, March TL, Vahrmeijer AL, Exner A, Bogyo M, Basilion JP, Straight B. Formulation of a Thermosensitive Imaging Hydrogel for Topical Application and Rapid Visualization of Tumor Margins in the Surgical Cavity. Cancers (Basel) 2022; 14:cancers14143459. [PMID: 35884520 PMCID: PMC9323389 DOI: 10.3390/cancers14143459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/11/2022] [Accepted: 07/12/2022] [Indexed: 01/07/2023] Open
Abstract
Simple Summary We have developed a formulation for an innovative, quenched, cathepsin-targeted, fluorescent molecular probe to enhance resection quality for several solid-tumor cancers. Unlike other formulations for imaging probes or tracers in development and entering the clinic, which require systemic administration hours before the procedure, this current formulation is applied topically into the surgical cavity immediately after a standard of care resection. Within minutes of application, the probe activates in the presence of residual cancer in the surgical wound and provides a strong fluorescent signal that precisely delineates any remaining cancer, enabling a more complete resection. Utilization of this imaging gel formulation for topical application to detect breast cancer in the surgical cavity during surgery has the potential to reduce re-excisions, with consequent savings in healthcare costs and enhancement in patient quality of life. Abstract Background: Tumor-positive surgical margins during primary breast cancer (BCa) surgery are associated with a two-fold increase in the risk of local recurrence when compared with tumor-negative margins. Pathological microscopic evaluation of the samples only assesses about 1/10 of 1% of the entire volume of the removed BCa specimens, leading to margin under-sampling and potential local recurrence in patients with pathologically clean margins, i.e., false negative margins. In the case of tumor-positive margins, patients need to undergo re-excision and/or radiation therapy, resulting in increases in complications, morbidity, and healthcare costs. Development of a simple real-time imaging technique to identify residual BCa in the surgical cavity rapidly and precisely could significantly improve the quality of care. Methods: A small-molecule, fluorescently quenched protease-substrate probe, AKRO-QC-ICG, was tested as part of a thermosensitive imaging gel formulated for topical application and imaging of the BCa surgical cavity. Results: More than forty formulations of gel mixtures were investigated to enable easy fluid application and subsequent solidification once applied, preventing dripping and pooling in the surgical cavity. The final formulation was tested using human BCa orthotopic implants in nude and NSG patient-derived xenografts (PDX) mice. This formulation of Pluronic F-127/DMSO/AKRO-QC-ICG imaging gel was found to be a good solvent for the probe, with a desirable thermo-reversible solid–gel transition and mechanical strength for distribution of AKRO-QC-ICG on the surfaces of tissue. It demonstrated excellent ability to detect BCa tissue after 10 min exposure, with a high signal-to-noise ratio both in mouse xenografts and freshly excised human lumpectomy tissue. The in vivo efficacy of the AKRO-QC-ICG imaging gel to detect BCa revealed the levels of sensitivity/specificity = 0.92/1 in 12 nude mice, which was corroborated with the sensitivity/specificity = 0.94/1 in 10 PDX mice. Conclusions: Utilization of Pluronic F-127/DMSO/AKRO-QC-ICG imaging gel for topical application to detect BCa in the surgical cavity during surgery has the potential to reduce re-excisions, with consequent savings in healthcare costs and enhancement in patient quality of life.
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Affiliation(s)
- Ethan Walker
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH 44106, USA; (E.W.); (X.W.); (A.E.); (J.P.B.)
| | - Daan G. J. Linders
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (D.G.J.L.); (O.D.B.); (A.L.V.)
| | - Eric Abenojar
- Department of Radiology, Case Western Reserve University, Cleveland, OH 44106, USA;
| | - Xinning Wang
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH 44106, USA; (E.W.); (X.W.); (A.E.); (J.P.B.)
| | - Hans Marten Hazelbag
- Department of Pathology, Haaglanden Medical Center, 2512 VA The Hague, The Netherlands;
| | - Marieke E. Straver
- Department of Surgery, Haaglanden Medical Center, 2512 VA The Hague, The Netherlands;
| | - Okker D. Bijlstra
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (D.G.J.L.); (O.D.B.); (A.L.V.)
| | - Taryn L. March
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
| | - Alexander L. Vahrmeijer
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (D.G.J.L.); (O.D.B.); (A.L.V.)
| | - Agata Exner
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH 44106, USA; (E.W.); (X.W.); (A.E.); (J.P.B.)
- Department of Radiology, Case Western Reserve University, Cleveland, OH 44106, USA;
| | - Matthew Bogyo
- Department of Pathology, Stanford University, Stanford, CA 94305, USA;
- Department of Microbiology and Immunology, Stanford University, Stanford, CA 94305, USA
| | - James P. Basilion
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH 44106, USA; (E.W.); (X.W.); (A.E.); (J.P.B.)
- Department of Radiology, Case Western Reserve University, Cleveland, OH 44106, USA;
- Akrotome Imaging Inc., Charlotte, NC 28205, USA
| | - Brian Straight
- Akrotome Imaging Inc., Charlotte, NC 28205, USA
- Correspondence: ; Tel.: +1-216-983-3264
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9
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Pan H, Qian M, Chen H, Wang H, Yu M, Zhang K, Wang S, Deng J, Xu Y, Ling L, Ding Q, Xie H, Wang S, Zhou W. Precision Breast-Conserving Surgery With Microwave Ablation Guidance: A Pilot Single-Center, Prospective Cohort Study. Front Oncol 2021; 11:680091. [PMID: 34123849 PMCID: PMC8187871 DOI: 10.3389/fonc.2021.680091] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 05/10/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction Negative margins in breast-conserving surgery (BCS) are essential for preventing recurrence. The aim of this study was to determine the use of preoperative microwave ablation (MWA) in the guidance of BCS for early-stage breast cancer and access whether MWA could influence the rates of positive resection margins. Methods From 2016 to 2018, 22 women with T1/T2 invasive breast cancer were enrolled for MWA prospectively in the guidance of BCS. US-guided MWA was performed under local anesthesia, followed by BCS and sentinel lymph node biopsy (SLNB) one week after ablation. Women who underwent palpation-guided BCS directly were included as control, and propensity score matching analysis was applied. Results MWA was performed in 22 patients. Of the 21 MWA cases with effect information, the mean tumor size in US was 20.9 ± 6.2 mm (6-37 mm). Compared with control group (BCS directly), a lower rate of positive/close margins was observed in MWA guidance group (P = 0.018), and MWA caused a higher rate of accurate surgery (the largest margin ≤ 3 cm and the smallest margin ≥ 1mm, P = 0.042). Of these 21 patients treated with MWA, 18 were candidates for SLNB. And sentinel lymph nodes were successfully identified in all cases, and no recurrence was found with a mean follow-up of 23 months. Conclusion For patients with T1/T2 breast cancer, the application of preoperative MWA could guide BCS accurately without impairing SLNB. Clinical trials with long-term results are required to validate MWA in the guidance for breast cancer excision.
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Affiliation(s)
- Hong Pan
- Department of Breast Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China.,Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center For Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Mengjia Qian
- Department of Breast Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China.,Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center For Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Hao Chen
- Department of Breast Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China.,Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center For Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Hui Wang
- Department of Breast Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China.,Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center For Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Muxin Yu
- Department of Breast Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China.,Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center For Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Kai Zhang
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center For Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, China.,Pancreatic Center & Department of General Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China.,Pancreas Institute of Nanjing Medical University, Nanjing, China
| | - Siqi Wang
- Department of Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Jing Deng
- Department of Ultrasonography, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Yi Xu
- Department of Pathology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Lijun Ling
- Department of Breast Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China.,Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center For Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Qiang Ding
- Department of Breast Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China.,Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center For Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Hui Xie
- Department of Breast Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China.,Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center For Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Shui Wang
- Department of Breast Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China.,Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center For Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Wenbin Zhou
- Department of Breast Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China.,Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center For Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, China
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10
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Wen Y, Truong VX, Li M. Real-Time Intraoperative Surface-Enhanced Raman Spectroscopy-Guided Thermosurgical Eradication of Residual Microtumors in Orthotopic Breast Cancer. NANO LETTERS 2021; 21:3066-3074. [PMID: 33820417 DOI: 10.1021/acs.nanolett.1c00204] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Residual microtumors following surgical resection are the major cause for lethal cancer recurrence. However, it remains challenging to completely eliminate these residual microtumors. Here, we report an integrated strategy for image-guided surgical resection of tumors and intraoperative surface-enhanced Raman spectroscopy (SERS) guided thermosurgical elimination of residual microtumors using a "three-in-one" theranostic nanoprobe, termed the Au nanostar-based photoacoustic (PA), SERS, and thermosurgical (starPART) probe. This starPART probe, comprising an Au nanostar core, a Raman molecule layer, and a silica outer layer, draws upon the significant advantages of PA imaging, SERS detection, and photothermal tumor ablation. These prominent features enable preoperative PA imaging for surgical resection of tumors and intraoperative SERS-guided thermosurgery for complete elimination of residual microtumors. In vivo experiments confirm complete eradication of microtumors without local recurrence and with a 100% tumor-free survivability. This work therefore offers a robust platform for real-time intraoperative eradication of residual microtumors with significant improvement of surgical outcomes.
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Affiliation(s)
- Yu Wen
- School of Materials Science and Engineering, Central South University, Changsha, Hunan 410083, China
| | - Vinh X Truong
- Centre for Materials Science, School of Physics and Chemistry, Queensland University of Technology, 2 George Street, Brisbane, QLD 4000, Australia
| | - Ming Li
- School of Materials Science and Engineering, Central South University, Changsha, Hunan 410083, China
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11
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Hu X, Li S, Jiang Y, Wei W, Ji Y, Li Q, Jiang Z. Intraoperative ultrasound-guided lumpectomy versus wire-guided excision for nonpalpable breast cancer. J Int Med Res 2020; 48:300060519896707. [PMID: 31937169 PMCID: PMC7113704 DOI: 10.1177/0300060519896707] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Objective This study was designed to compare the margin clearance and re-excision rates of ultrasound (US)- and wire-guided excision in a large number of patients with nonpalpable breast cancer. Methods In total, 520 women who were histologically diagnosed with nonpalpable breast cancer were recruited in this study. All nonpalpable lesions were visible by US. The patients were randomly divided into two groups: those who underwent wire-guided breast-conserving surgery (BCS) and those who underwent US-guided BCS. Re-excision rates and positive surgical margins were recorded. Results A total of 262 patients underwent US-guided excision and 258 patients underwent wire-guided excision. No differences were found in tumor or patient characteristics. The positive margin rate was 4.6% in the US-guided group and 19.4% in the wire-guided group with a significant difference. Age, menopausal status, excision volume, histological grade, and tumor type significantly influenced the positive surgical margin rate. The intraoperative re-excision rate was significantly lower in the US-guided group than wire-guided group (11.1% vs. 24.0%, respectively). Conclusions US-guided BCS seems to be more effective than wire-guided BCS for treatment of nonpalpable breast cancers in terms of the margin clearance and re-excision rates. Patients can avoid the discomfort caused by preoperative wire placement.
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Affiliation(s)
- Xin Hu
- Department of Pain Management, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Si Li
- Department of Breast Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Yi Jiang
- Department of Breast Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Wei Wei
- Department of Breast Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Yinan Ji
- Department of Breast Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Qiuyun Li
- Department of Breast Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Zongbin Jiang
- Department of Pain Management, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
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12
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Ozmen T, Avisar E. The Impact of Advanced Image-Guided Breast Surgery and Oncoplastic Techniques on Margin Positivity in Breast Conserving Surgery. Cureus 2020; 12:e11831. [PMID: 33409073 PMCID: PMC7781498 DOI: 10.7759/cureus.11831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Objective Positive margins remain a significant psychological and economic burden after breast conserving surgery. The aim of this study was to test the hypothesis that advanced oncoplastic techniques as well as intraoperative integrative imaging with intraoperative ultrasound and mobile digital specimen radiography decreases positive margin rate in breast conserving surgery. Methods A single-institution retrospective review of a prospectively collected database was performed. Patients with breast neoplasms who underwent lumpectomy with or without using intraoperative integrative imaging approaches and oncoplastic techniques were included. The primary outcome was positive margin rate for each technique. Results A total of 392 patients were included in the study. The median age of the cohort was 59 years. Overall positive margin rate was 15%. Ductal carcinoma in situ (DCIS) histology and larger tumor size were associated with higher positive margin rate. Intraoperative integrative imaging significantly decreased positive margin rate (9% vs. 18%, p=0.018). Oncoplastic techniques also decreased positive margin rate from 16% to 12%, however this was not significant. Conclusion Positive margin rate was significantly lower when intraoperative integrative imaging was used. Oncoplastic techniques also decreased positive margin rate in a selected group of patients with large tumor size. We suggest incorporating these techniques in all breast conserving surgery cases.
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Affiliation(s)
- Tolga Ozmen
- Surgical Oncology, University of Miami, Miller School of Medicine, Miami, USA
| | - Eli Avisar
- Surgical Oncology, University of Miami, Miller School of Medicine, Miami, USA
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13
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Kennedy KM, Zilkens R, Allen WM, Foo KY, Fang Q, Chin L, Sanderson RW, Anstie J, Wijesinghe P, Curatolo A, Tan HEI, Morin N, Kunjuraman B, Yeomans C, Chin SL, DeJong H, Giles K, Dessauvagie BF, Latham B, Saunders CM, Kennedy BF. Diagnostic Accuracy of Quantitative Micro-Elastography for Margin Assessment in Breast-Conserving Surgery. Cancer Res 2020; 80:1773-1783. [PMID: 32295783 DOI: 10.1158/0008-5472.can-19-1240] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 08/09/2019] [Accepted: 02/14/2020] [Indexed: 01/16/2023]
Abstract
Inadequate margins in breast-conserving surgery (BCS) are associated with an increased likelihood of local recurrence of breast cancer. Currently, approximately 20% of BCS patients require repeat surgery due to inadequate margins at the initial operation. Implementation of an accurate, intraoperative margin assessment tool may reduce this re-excision rate. This study determined, for the first time, the diagnostic accuracy of quantitative micro-elastography (QME), an optical coherence tomography (OCT)-based elastography technique that produces images of tissue microscale elasticity, for detecting tumor within 1 mm of the margins of BCS specimens. Simultaneous OCT and QME were performed on the margins of intact, freshly excised specimens from 83 patients undergoing BCS and on dissected specimens from 7 patients undergoing mastectomy. The resulting three-dimensional images (45 × 45 × 1 mm) were coregistered with postoperative histology to determine tissue types present in each scan. Data from 12 BCS patients and the 7 mastectomy patients served to build a set of images for reader training. One hundred and fifty-four subimages (10 × 10 × 1 mm) from the remaining 71 BCS patients were included in a blinded reader study, which resulted in 69.0% sensitivity and 79.0% specificity using OCT images, versus 92.9% sensitivity and 96.4% specificity using elasticity images. The quantitative nature of QME also facilitated development of an automated reader, which resulted in 100.0% sensitivity and 97.7% specificity. These results demonstrate high accuracy of QME for detecting tumor within 1 mm of the margin and the potential for this technique to improve outcomes in BCS. SIGNIFICANCE: An optical imaging technology probes breast tissue elasticity to provide accurate assessment of tumor margin involvement in breast-conserving surgery.
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Affiliation(s)
- Kelsey M Kennedy
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, and Centre for Medical Research, The University of Western Australia, Perth, 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, Australia.,School of Medicine, The University of Western Australia, Perth, 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, Australia.,Department of Electrical, Electronic & Computer Engineering, School of Engineering, The University of Western Australia, Perth, 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, Australia.,Department of Electrical, Electronic & Computer Engineering, School of Engineering, The University of Western Australia, Perth, 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, Australia.,Department of Electrical, Electronic & Computer Engineering, School of Engineering, The University of Western Australia, Perth, 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, Australia.,Department of Electrical, Electronic & Computer Engineering, School of Engineering, The University of Western Australia, Perth, 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, Australia.,Department of Electrical, Electronic & Computer Engineering, School of Engineering, The University of Western Australia, Perth, Australia
| | - James Anstie
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, and Centre for Medical Research, The University of Western Australia, Perth, Australia.,Department of Electrical, Electronic & Computer Engineering, School of Engineering, The University of Western Australia, Perth, Australia
| | - Philip Wijesinghe
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, and Centre for Medical Research, The University of Western Australia, Perth, Australia.,Department of Electrical, Electronic & Computer Engineering, School of Engineering, The University of Western Australia, Perth, Australia
| | - Andrea Curatolo
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, and Centre for Medical Research, The University of Western Australia, Perth, Australia.,Department of Electrical, Electronic & Computer Engineering, School of Engineering, The University of Western Australia, Perth, Australia
| | - Hsern Ern I Tan
- School of Medicine, The University of Western Australia, Perth, Australia
| | | | | | - Chris Yeomans
- PathWest, Fiona Stanley Hospital, Murdoch, Australia
| | - Synn Lynn Chin
- Breast Centre, Fiona Stanley Hospital, Murdoch, Australia
| | - Helen DeJong
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, and Centre for Medical Research, The University of Western Australia, Perth, Australia
| | | | - Benjamin F Dessauvagie
- School of Medicine, The University of Western Australia, Perth, Australia.,PathWest, Fiona Stanley Hospital, Murdoch, Australia
| | - Bruce Latham
- PathWest, Fiona Stanley Hospital, Murdoch, Australia
| | - Christobel M Saunders
- School of Medicine, The University of Western Australia, Perth, Australia.,Breast Centre, Fiona Stanley Hospital, Murdoch, Australia.,Breast Clinic, Royal Perth Hospital, Perth, 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, Australia. .,Department of Electrical, Electronic & Computer Engineering, School of Engineering, The University of Western Australia, Perth, Australia
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14
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Tasdöven I, Karadeniz Çakmak G, Emre AU, Engin H, Bahadır B, Bakkal HB, Güllüoğlu MB. Intraoperative ultrasonography-guided surgery: An effective modality for breast conservation after neo-adjuvant chemotherapy. Breast J 2020; 26:1680-1687. [PMID: 33443786 DOI: 10.1111/tbj.13992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 06/05/2020] [Accepted: 07/10/2020] [Indexed: 11/28/2022]
Abstract
Margin status is one of the significant prognostic factors for recurrence in breast-conserving surgery (BCS). The issue that merits consideration for oncologic safety and cost-effectiveness about the modalities to assure clear margins at initial surgical intervention remains controversial after neo-adjuvant chemotherapy (NAC). The presented study aimed to assess the impact of intraoperative ultrasound (IOUS)-guided surgery on accurate localization of tumor site, adequacy of excision with clear margins, and healthy tissue sacrifice in BCS after NAC. Patients who had IOUS-guided BCS ater NAC were reviewed. No patient had preoperative localization with wire or radiotracer. Intraoperative real-time sonographic localization, sonographic margin assessment during resection, macroscopic and sonographic examination of specimen, and cavity shavings (CS) were done as the standard procedure. No frozen assessment was performed. One hundred ninety-four patients were included, in which 42.5% had pCR. IOUS-guided surgery accomplished successful localization of the targeted lesions in all patients. Per protocol, all inked margins on CS specimens were reported to be tumor-free in permanent histopathology. No re-excision or mastectomy was required. For a setting without CS, the negative predictive value (NPV) of IOUS rate was 96%. IOUS was found to over and underestimate tumor response to NAC both in 2% of patients. IOUS-guided surgery seems to be an efficient modality to perform adequate BCS after NAC with no additional localization method. Especially, when CS is integrated as a standard to BCS, IOUS seems to provide safe surgery for patients with no false negativity and a high rate of NPV.
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Affiliation(s)
- Ilhan Tasdöven
- Department of Surgery, The School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | - Güldeniz Karadeniz Çakmak
- Department of Surgery, The School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | - Ali Ugur Emre
- Department of Surgery, The School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | - Hüseyin Engin
- Department of Oncology, The School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | - Burak Bahadır
- Department of Pathology, The School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | - Hakan Bekir Bakkal
- Department of Radiation Oncology, The School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
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15
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Use of Intraoperative Ultrasound During Breast Conservation Surgery (BCS) for Palpable Breast Cancer: an Extremely Effective Approach with Improved Oncological Outcome. Indian J Surg Oncol 2019; 10:600-607. [PMID: 31857750 DOI: 10.1007/s13193-019-00934-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 05/02/2019] [Indexed: 10/26/2022] Open
Abstract
For clinically low-volume breast cancer patients subjected to BCS, there is a concern regarding achieving microscopically negative margins and avoiding inadvertent resection of excessive volume of breast tissue. In this study, we utilized intraoperative ultrasound to guide resection in patients subjected to BCS. This was compared with palpation-guided resection. A total of 80 patients of invasive breast carcinoma (T1-2, N0-1, M0) (39 patients in USG-guided BCS (group A) and 41 patients in palpation-guided BCS (group B)) were enrolled. In group A, intraoperative localization was performed using a multifrequency 10-MHz linear array ultrasound probe and tumors were excised under USG guidance. In group B, tumor excision was guided by the palpation skills of the surgeon with the aim of achieving grossly negative margin circumferentially. Specimen volume was measured using water displacement technique. One out of 39 patients (2.56%) in group A and 5 out of 41(12.19%) in group B had positive margin in histopathology report. Mean of specimen volume in groups A and B was 42.67 and 57.97 ml respectively (P = 0.011). Mean of excess volume removed in study group was 4.19 ml and in control group, it was 24.11 ml (P = < 0.01). Mean of calculated resection ratio in study group was 1.1 and in control group was 1.73 (P = 0.01). Use of intraoperative ultrasound during BCS may help in improving margin clearance, reducing additional procedures, and preserving the normal breast parenchyma. The safety, ease, and effectivity of this technique may result in its wider application in future.
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16
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Esgueva A, Rodríguez-Revuelto R, Espinosa-Bravo M, Salazar JP, Rubio IT. Learning curves in intraoperative ultrasound guided surgery in breast cancer based on complete breast cancer excision and no need for second surgeries. Eur J Surg Oncol 2019; 45:578-583. [DOI: 10.1016/j.ejso.2019.01.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 12/11/2018] [Accepted: 01/11/2019] [Indexed: 01/05/2023] Open
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17
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Intraoperative ultrasound in breast cancer surgery-from localization of non-palpable tumors to objectively measurable excision. World J Surg Oncol 2018; 16:184. [PMID: 30205823 PMCID: PMC6134720 DOI: 10.1186/s12957-018-1488-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 09/05/2018] [Indexed: 01/08/2023] Open
Abstract
Background The utilization of intraoperative ultrasound (IOUS) in breast cancer surgery is a relatively new concept in surgical oncology. Over the last few decades, the field of breast cancer surgery has been striving for a more rational approach, directing its efforts towards removing the tumor entirely yet sparing tissue and structures not infiltrated by tumor cells. Further progress in objectivity and optimization of breast cancer excision is possible if we make the tumor and surrounding tissue visible and measurable in real time, during the course of the operation; IOUS seems to be the optimal solution to this complex requirement. IOUS was introduced into clinical practice as a device for visualization of non-palpable tumors, and compared to wire-guided localization (WGL), IOUS was always at least a viable, or much better alternative, in terms of both precision in identification and resection and for patients’ and surgeons’ comfort. In recent years, intraoperative ultrasound has been used in the surgery of palpable tumors to optimize resection procedures and overcome the disadvantages of classic palpation guided surgery. Objective The aim of this review is to show the role of IOUS in contemporary breast cancer surgery and its changes over time. Methods A PubMed database comprehensive search was conducted to identify all relevant articles according to assigned key words. Conclusion Over time, the use of IOUS has been transformed from being the means of localizing non-palpable lesions to an instrument yielding a reduced number of positive resection margins, with a smaller volume of healthy breast tissue excided around tumor, by making the excision of the tumor optimal and objectively measurable.
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18
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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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19
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Pop MM, Cristian S, Hanko-Bauer O, Ghiga DV, Georgescu R. Obtaining adequate surgical margin status in breast-conservation therapy: intraoperative ultrasound-guided resection versus specimen mammography. ACTA ACUST UNITED AC 2018; 91:197-202. [PMID: 29785158 PMCID: PMC5958985 DOI: 10.15386/cjmed-891] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 12/01/2017] [Accepted: 01/24/2018] [Indexed: 11/23/2022]
Abstract
Background and aim The purpose of breast-conserving surgery (BCS) for women with cancer is to perform an oncological radical procedure with disease-free margins at the final histological assessment and with the best aesthetic result possible. Intraoperative resected specimen ultrasound and intraoperative resected specimen mammography may reduce the rates of positive margins and reexcision among patients undergoing conserving therapy. Our objective is to compare the two methods with the histopathological results for a preset cut off and asses which parameters can influence the positive margin status. Method A prospective study was performed on 83 patients who underwent breast conservation surgery for early breast cancer (pT1-3a pN0-1 M0) between 2014 and 2016. After excision the specimen was oriented in the operating room by the surgeon. Metallic clips and threads were placed on margins: one clip and the long thread at 12 o’clock, two clips and the short threads at 9 o’clock. The next step was intraoperative ultrasound assessment of the specimen. For the margins under 2 mm we performed selective margin shaving, followed by mammography to identify and document the lesion and finally histopathological examination of the specimen with reporting the gross and microscopic margins. The positive margins required re-excision or boost of radiation at the posterior or anterior margins, depending on the case. Results We set a cut-off at 2 mm. The sensitivity and specificity of the intraoperative margin assessment via the ultrasound method were 90.91% (95% CI 70.84–98.88%) and 67.21% (95% CI 54–78.69%) respectively. The sensitivity and specificity of the intraoperative margin assessment via the mammographic procedure were 45.45% (95% CI 24.39–67.79%) and 85.25% (95% CI 73.83–93.02%) respectively. There was positive correlation between the histopathological and intraoperative ultrasound exam (p=0.018) and negative correlation between the histopathological exam and the post-operative mammographic exam (p=0.68). We found a positive correlation between the positive margin status and age (<40), preoperative chemotherapy, intraductal carcinoma, inflammatory process around the tumor, and the immunohistochemical triple negative profile. Conclusions According to our results, the intraoperative ultrasound of the breast specimen for a cutt-off at 2 mm can decrease the rates of margin positivity compared to the mammographic procedure and has the potential to diminish the number of subsequent undesired re-excisions.
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Affiliation(s)
- Maria Mihaela Pop
- General Medicine, University of Medicine and Pharmacy of Tîrgu Mureş, Romania
| | - Silviu Cristian
- General Medicine, University of Medicine and Pharmacy of Tîrgu Mureş, Romania
| | - Orsolya Hanko-Bauer
- Department of Surgery, University of Medicine and Pharmacy of Tîrgu Mureş, Romania
| | - Dana Valentina Ghiga
- Department of Research Methodology, University of Medicine and Pharmacy of Tîrgu Mureş, Romania
| | - Rares Georgescu
- Department of Surgery, University of Medicine and Pharmacy of Tîrgu Mureş, Romania
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Carmon M, Zilber S, Gekhtman D, Olsha O, Hadar T, Golomb E. Hygroscopic sonographically detectable clips form characteristic breast and lymph node pseudocysts. Mod Pathol 2018; 31:62-67. [PMID: 28799535 DOI: 10.1038/modpathol.2017.96] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Revised: 06/11/2017] [Accepted: 06/18/2017] [Indexed: 11/09/2022]
Abstract
The use of hygroscopic sonographically detectable clips (HSDCs) has dramatically increased during the last years, especially in breast cancer patients who undergo neoadjuvant chemotherapy. The aims of this study are to define the appearance of HSDC sites in histopathological specimens, and to enable pathologists to recognize these sites and differentiate them from other lesions. We examined 124 breast cancer specimens in which the application of HSDCs was documented, 88 breast tissues and 36 lymph nodes, and analyzed the appearance of the clip site in these tissues. The clip site was clearly detected histologically in 79/88 (90%) of the breast specimens and in 29/36 (81%) of lymph node specimens. In most of the specimens, the HSDC site had a specific characteristic appearance of a pseudocyst, lined by layers of epithelioid histiocytes, sometimes with pseudopapillary formation, and with minimal or no fibrosis. This was the appearance in 69 of the breast specimens and in 23 of the lymph node specimens. In other specimens, scarring, scattered foamy macrophages and abundant siderophages were the predominant findings, as usually found in sites of other clips. As non-palpable breast lesions become more frequent, clips play a major role in the treatment of breast cancer, making them an important component of the communication among radiologists, surgeons, pathologists, and oncologists. HSDCs in tissues have a characteristic appearance with an epithelioid component. Pathologists should be able to recognize this finding, differentiate it from other breast lesions and include it in the pathology report.
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Affiliation(s)
- Moshe Carmon
- Breast Health Unit, Shaare Zedek Medical Center, Hebrew University, Jerusalem, Israel
| | - Sofia Zilber
- Department of Pathology, Shaare Zedek Medical Center, Hebrew University, Jerusalem, Israel
| | - David Gekhtman
- Department of Breast Imaging, Shaare Zedek Medical Center, Hebrew University, Jerusalem, Israel
| | - Oded Olsha
- Breast Health Unit, Shaare Zedek Medical Center, Hebrew University, Jerusalem, Israel
| | - Tal Hadar
- Breast Health Unit, Shaare Zedek Medical Center, Hebrew University, Jerusalem, Israel
| | - Eliahu Golomb
- Department of Pathology, Shaare Zedek Medical Center, Hebrew University, Jerusalem, Israel
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Arko D, Čas Sikošek N, Kozar N, Sobočan M, Takač I. The value of ultrasound-guided surgery for breast cancer. Eur J Obstet Gynecol Reprod Biol 2017; 216:198-203. [DOI: 10.1016/j.ejogrb.2017.07.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 07/26/2017] [Accepted: 07/27/2017] [Indexed: 12/16/2022]
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Karadeniz Cakmak G, Emre AU, Tascilar O, Bahadir B, Ozkan S. Surgeon performed continuous intraoperative ultrasound guidance decreases re-excisions and mastectomy rates in breast cancer. Breast 2017; 33:23-28. [DOI: 10.1016/j.breast.2017.02.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 12/11/2016] [Accepted: 02/22/2017] [Indexed: 01/14/2023] Open
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Carmon M, Olsha O, Gekhtman D, Nikitin I, Cohen Y, Messing M, Lioubashevsky N, Abu Dalo R, Hadar T, Golomb E. Detectability of Hygroscopic Clips Used in Breast Cancer Surgery. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2017; 36:401-408. [PMID: 28039936 DOI: 10.7863/ultra.16.02053] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 04/25/2016] [Indexed: 06/06/2023]
Abstract
Sonographically detectable clips were introduced over the last decade. We retrospectively studied the rate and duration of sonographically detectable clip detectability in patients with breast cancer who had sonographically detectable clips inserted over a 2-year period. Nine of 26 patients had neoadjuvant chemotherapy, with all clips remaining detectable 140 to 187 days after insertion. Six of the 9 had intraoperative sonographic localization, with 1 reoperation (17%). Eleven additional patients with nonpalpable tumors and sonographically detectable clips had intraoperative sonographic localization with 1 reoperation (9%). In 1 patient, a sonographically detectable clip enabled intraoperative identification of a suspicious lymph node. There were no complications or clip migration. Sonographically detectable clips are helpful in breast cancer surgery with and without neoadjuvant chemotherapy, remaining detectable for many months and often averting preoperative localization and scheduling difficulties.
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Affiliation(s)
- Moshe Carmon
- Breast Health Unit, Shaare Zedek Medical Center, Hebrew University, Jerusalem, Israel
| | - Oded Olsha
- Breast Health Unit, Shaare Zedek Medical Center, Hebrew University, Jerusalem, Israel
| | - David Gekhtman
- Breast Imaging Unit, Shaare Zedek Medical Center, Hebrew University, Jerusalem, Israel
| | - Irena Nikitin
- Breast Imaging Unit, Shaare Zedek Medical Center, Hebrew University, Jerusalem, Israel
| | - Yamin Cohen
- Hala: the Rachel Nash Jerusalem Comprehensive Breast Clinic, Jerusalem, Israel
| | - Michael Messing
- Hala: the Rachel Nash Jerusalem Comprehensive Breast Clinic, Jerusalem, Israel
| | | | - Ribhi Abu Dalo
- Breast Health Unit, Shaare Zedek Medical Center, Hebrew University, Jerusalem, Israel
| | - Tal Hadar
- Breast Health Unit, Shaare Zedek Medical Center, Hebrew University, Jerusalem, Israel
| | - Eliahu Golomb
- Department of Pathology, Shaare Zedek Medical Center, Hebrew University, Jerusalem, Israel
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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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Laws A, Brar MS, Bouchard-Fortier A, Leong B, Quan ML. Intraoperative Margin Assessment in Wire-Localized Breast-Conserving Surgery for Invasive Cancer: A Population-Level Comparison of Techniques. Ann Surg Oncol 2016; 23:3290-6. [DOI: 10.1245/s10434-016-5401-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Indexed: 11/18/2022]
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26
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Espinosa-Bravo M, Rubio IT. Intraoperative ultrasound guided breast surgery: paving the way for personalized surgery. Gland Surg 2016; 5:366-8. [PMID: 27294242 DOI: 10.21037/gs.2016.03.06] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Martin Espinosa-Bravo
- Breast Surgical Oncology, Breast Cancer Center, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Isabel T Rubio
- Breast Surgical Oncology, Breast Cancer Center, Hospital Universitario Vall d'Hebron, Barcelona, Spain
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Dixon JM, Newlands C, Dodds C, Thomas J, Williams LJ, Kunkler IH, Bing A, Macaskill EJ. Association between underestimation of tumour size by imaging and incomplete excision in breast-conserving surgery for breast cancer. Br J Surg 2016; 103:830-8. [DOI: 10.1002/bjs.10126] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 09/18/2015] [Accepted: 01/06/2016] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Completeness of excision is the most important factor influencing local recurrence after breast-conserving surgery (BCS). The aim of this case–control study was to determine factors influencing incomplete excision in patients undergoing BCS.
Methods
Women with invasive breast cancer treated by BCS between 1 June 2008 and 31 December 2009 were identified from a prospectively collected database in the Edinburgh Breast Unit. The maximum size of the tumour, measured microscopically, was compared with the size estimated before operation by mammography and ultrasound imaging. A multivariable analysis was performed to investigate factors associated with incomplete excision.
Results
The cohort comprised 311 women, of whom 193 (62·1 per cent) had a complete (CE group) and 118 (40·7 per cent) an incomplete (IE group) excision. Mammography underestimated tumour size in 75·0 per cent of the IE group compared with 40·7 per cent of the CE group (P < 0·001). Ultrasound imaging underestimated tumour size in 82·5 per cent of the IE group compared with 56·5 per cent of the CE group (P < 0·001). The risk of an incomplete excision was greater when mammography or ultrasonography underestimated pathological size: odds ratio (OR) 4·38 (95 per cent c.i. 2·59 to 7·41; P < 0·001) for mammography, and OR 3·64 (2·03 to 6·54; P < 0·001) for ultrasound imaging. For every 1-mm underestimation of size by mammography and ultrasonography, the relative odds of incomplete excision rose by 10 and 14 per cent respectively.
Conclusion
Underestimation of tumour size by current imaging techniques is a major factor associated with incomplete excision in women undergoing BCS.
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Affiliation(s)
- J M Dixon
- Edinburgh Breast Unit, University of Edinburgh, Edinburgh, UK
| | - C Newlands
- Edinburgh University Medical School, University of Edinburgh, Edinburgh, UK
| | - C Dodds
- South East Scotland Cancer Network, NHS Lothian, University of Edinburgh, Edinburgh, UK
| | - J Thomas
- Edinburgh Breast Unit, University of Edinburgh, Edinburgh, UK
| | - L J Williams
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - I H Kunkler
- Edinburgh Breast Unit, University of Edinburgh, Edinburgh, UK
| | - A Bing
- Edinburgh Breast Unit, University of Edinburgh, Edinburgh, UK
| | - E J Macaskill
- Department of Breast Surgery, Ninewells Hospital and Medical School, Dundee, UK
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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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Haloua MH, Volders JH, Krekel NMA, Barbé E, Sietses C, Jóźwiak K, Meijer S, van den Tol MP. A nationwide pathology study on surgical margins and excision volumes after breast-conserving surgery: There is still much to be gained. Breast 2015; 25:14-21. [PMID: 26801411 DOI: 10.1016/j.breast.2015.11.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 10/23/2015] [Accepted: 11/14/2015] [Indexed: 01/08/2023] Open
Abstract
AIM OF THE STUDY The current study aims to assess margin status in relation to amount of healthy breast tissue resected in breast-conserving surgery (BCS) on a nationwide scale. METHODS Using PALGA (a nationwide network and registry of histology and cytopathology in the Netherlands), all patients who underwent BCS for primary invasive carcinoma in 2012-13 were selected (10,058 excerpts). 9276 pathology excerpts were analyzed for a range of criteria including oncological margin status and distance to closest margin, specimen weight/volume, greatest tumor diameter, and with or without localization method. Calculated resection ratios (CRR) were assessed to determine excess healthy breast tissue resection. RESULTS Margins for invasive carcinoma and in situ carcinoma combined were tumor-involved in 498 (5.4%) and focally involved in 1021 cases (11.0%) of cases. Unsatisfactory resections including (focally) involved margins and margins ≤ 1 mm were reported in 33.8% of patients. The median lumpectomy volume was 46 cc (range 1-807 cc; SD 49.18) and median CRR 2.32 (range 0.10-104.17; SD 3.23), indicating the excision of 2.3 the optimal resection volume. CONCLUSION The unacceptable rate of tumor-involved margins as well as margins ≤ 1 mm in one third of all patients is also achieved at the expense of healthy breast tissue resection, which may carry the drawback of high rates of cosmetic failure. These data clearly suggest the need for improvement in current breast conserving surgical procedures to decrease tumor-involved margin rates while reducing the amount of healthy breast tissue resected.
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Affiliation(s)
- M H Haloua
- Department of Surgical Oncology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
| | - J H Volders
- Department of Surgical Oncology, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP Ede, The Netherlands
| | - N M A Krekel
- Department of Surgical Oncology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
| | - E Barbé
- Department of Pathology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
| | - C Sietses
- Department of Surgical Oncology, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP Ede, The Netherlands
| | - K Jóźwiak
- Department of Epidemiology and Biostatistics, NKI-AVL, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - S Meijer
- Department of Surgical Oncology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - M P van den Tol
- Department of Surgical Oncology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
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Karanlik H, Ozgur I, Sahin D, Fayda M, Onder S, Yavuz E. Intraoperative ultrasound reduces the need for re-excision in breast-conserving surgery. World J Surg Oncol 2015; 13:321. [PMID: 26596699 PMCID: PMC4657358 DOI: 10.1186/s12957-015-0731-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 11/06/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The purpose of this study was to evaluate ultrasound-guided surgery for palpable breast cancer by comparing the standard palpation-guided surgery in terms of the extent of healthy breast tissue resection, the percentage of tumor-free margins, and cosmetic outcomes. METHODS This was a prospective, observational cohort study conducted from January 2009 to July 2011. Breast cancer patients, diagnosed via biopsy, were operated in guidance with either ultrasound or palpation. Patient demographics, tumor features, intraoperative findings, pathologic and cosmetic results, intraoperative-measured ultrasound margins, and pathology margins were compared. RESULTS Ultrasound (US)-guided lumpectomy was performed on 84 women and palpation-guided lumpectomy on 80 women. Patient demographics and tumor characteristics showed no differences. The rate of re-excision was 17 % for the palpation-guided surgery group, and 6 % for the US-guided group (p = 0.03). There was good correlation between the closest margins recorded by US and pathology margins (r = 0.76, p = 0.01). Volume of resection was significantly larger in the palpation-guided group despite the similar size of tumors (p = 0.048). Cosmetic outcome of surgery was equivalent between groups. CONCLUSIONS Intraoperative ultrasound guidance for excision of palpable breast cancers is feasible and gives results in terms of pathologic margins that are comparable with those achieved by standard palpation-guided excisions.
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Affiliation(s)
- Hasan Karanlik
- Surgical Oncology Unit, Institute of Oncology, Istanbul University, Istanbul, Turkey.
| | - Ilker Ozgur
- Department of General Surgery, Acibadem International Hospital, Bakirkoy, Istanbul, Turkey
| | - Dilek Sahin
- Department of Radiology, Institute of Oncology, Istanbul University, Istanbul, Turkey
| | - Merdan Fayda
- Department of Radiation Oncology, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Semen Onder
- Department of Pathology, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Ekrem Yavuz
- Department of Pathology, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
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Kennedy KM, Chin L, McLaughlin RA, Latham B, Saunders CM, Sampson DD, Kennedy BF. Quantitative micro-elastography: imaging of tissue elasticity using compression optical coherence elastography. Sci Rep 2015; 5:15538. [PMID: 26503225 PMCID: PMC4622092 DOI: 10.1038/srep15538] [Citation(s) in RCA: 145] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 09/28/2015] [Indexed: 01/22/2023] Open
Abstract
Probing the mechanical properties of tissue on the microscale could aid in the identification of diseased tissues that are inadequately detected using palpation or current clinical imaging modalities, with potential to guide medical procedures such as the excision of breast tumours. Compression optical coherence elastography (OCE) maps tissue strain with microscale spatial resolution and can delineate microstructural features within breast tissues. However, without a measure of the locally applied stress, strain provides only a qualitative indication of mechanical properties. To overcome this limitation, we present quantitative micro-elastography, which combines compression OCE with a compliant stress sensor to image tissue elasticity. The sensor consists of a layer of translucent silicone with well-characterized stress-strain behaviour. The measured strain in the sensor is used to estimate the two-dimensional stress distribution applied to the sample surface. Elasticity is determined by dividing the stress by the strain in the sample. We show that quantification of elasticity can improve the ability of compression OCE to distinguish between tissues, thereby extending the potential for inter-sample comparison and longitudinal studies of tissue elasticity. We validate the technique using tissue-mimicking phantoms and demonstrate the ability to map elasticity of freshly excised malignant and benign human breast tissues.
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Affiliation(s)
- Kelsey M Kennedy
- Optical+Biomedical Engineering Laboratory, School of Electrical, Electronic &Computer Engineering, The University of Western Australia, 35 Stirling Highway, Crawley WA 6009, Australia
| | - Lixin Chin
- Optical+Biomedical Engineering Laboratory, School of Electrical, Electronic &Computer Engineering, The University of Western Australia, 35 Stirling Highway, Crawley WA 6009, Australia
| | - Robert A McLaughlin
- Optical+Biomedical Engineering Laboratory, School of Electrical, Electronic &Computer Engineering, The University of Western Australia, 35 Stirling Highway, Crawley WA 6009, Australia
| | - Bruce Latham
- PathWest, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, WA 6150, Australia
| | - Christobel M Saunders
- School of Surgery, The University of Western Australia, 35 Stirling Highway, Crawley, WA 6009, Australia.,Breast Clinic, Royal Perth Hospital, 197 Wellington Street, Perth, WA 6000, Australia
| | - David D Sampson
- Optical+Biomedical Engineering Laboratory, School of Electrical, Electronic &Computer Engineering, The University of Western Australia, 35 Stirling Highway, Crawley WA 6009, Australia.,Centre for Microscopy, Characterisation &Analysis, The University of Western Australia, 35 Stirling Highway, Crawley, WA 6009, Australia
| | - Brendan F Kennedy
- Optical+Biomedical Engineering Laboratory, School of Electrical, Electronic &Computer Engineering, The University of Western Australia, 35 Stirling Highway, Crawley WA 6009, Australia
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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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Ivanovic NS, Zdravkovic DD, Skuric Z, Kostic J, Colakovic N, Stojiljkovic M, Opric S, Stefanovic Radovic M, Soldatovic I, Sredic B, Granic M. Optimization of breast cancer excision by intraoperative ultrasound and marking needle - technique description and feasibility. World J Surg Oncol 2015; 13:153. [PMID: 25896818 PMCID: PMC4404261 DOI: 10.1186/s12957-015-0568-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 04/04/2015] [Indexed: 12/30/2022] Open
Abstract
Background We present a surgical technique and the preliminary results of breast cancer excision after insertion of a specially constructed marking needle into the tumor, controlled by intraoperative ultrasound. Resection margins were projected in six directions by ultrasound measurements, determined in relation to the needle, and resection was done in accordance with those measurements. The main objective was to obtain resection margins similar (equal) to those projected by intraoperative ultrasound (10 mm). Methods Detailed description of the technique is given. Thirty-two female patients undergoing breast-conserving surgery, up to 30 mm in diameter, for palpable and non-palpable invasive breast cancer, were operated on using this technique. Its feasibility was tested by analyzing the success (rate) of needle placement in the tumor, the measurements executed, and the performance of the excision. Results All stages of the technique were successfully performed to completion on all 32 patients. The procedure of needle placement and ultrasound measurement of distances took 11 min on average (between 6 and 20 min). The average distance of the tumor margin from the resection margin was 12.9 mm (2 to 30 mm, 95% confidence interval [11.9, 14.06]). There was one patient with a positive resection margin (3%). Conclusions The technique of excising palpable and non-palpable breast cancer by intraoperative ultrasound and an especially constructed marking needle is feasible and comfortable to perform. Preliminary results imply that resection volume can be rationalized, with the same or better oncological safety.
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Affiliation(s)
- Nebojsa S Ivanovic
- Department of Surgical Oncology, UMC Bezanijska Kosa, Autoput bb, Belgrade, 11000, Serbia. .,Medical Faculty of Belgrade University, Dr Subotica 8, Belgrade, 11000, Serbia.
| | - Darko D Zdravkovic
- Department of Surgical Oncology, UMC Bezanijska Kosa, Autoput bb, Belgrade, 11000, Serbia. .,Medical Faculty of Belgrade University, Dr Subotica 8, Belgrade, 11000, Serbia.
| | - Zlatko Skuric
- Department of Surgical Oncology, UMC Bezanijska Kosa, Autoput bb, Belgrade, 11000, Serbia.
| | - Jelena Kostic
- Department of Surgical Oncology, UMC Bezanijska Kosa, Autoput bb, Belgrade, 11000, Serbia.
| | - Natasa Colakovic
- Department of Surgical Oncology, UMC Bezanijska Kosa, Autoput bb, Belgrade, 11000, Serbia.
| | - Miodrag Stojiljkovic
- Department of Pathology, UMC Bezanijska kosa, Autoput bb, Belgrade, 11000, Serbia.
| | - Svetlana Opric
- Department of Pathology, UMC Bezanijska kosa, Autoput bb, Belgrade, 11000, Serbia.
| | | | - Ivan Soldatovic
- Department of Statistics, Medical faculty of Belgrade University, Dr Subotica 8, Belgrade, 11000, Serbia.
| | - Biljana Sredic
- Department of Surgical Oncology, UMC Bezanijska Kosa, Autoput bb, Belgrade, 11000, Serbia.
| | - Miroslav Granic
- Department of Surgical Oncology, UMC Bezanijska Kosa, Autoput bb, Belgrade, 11000, Serbia. .,Medical Faculty of Belgrade University, Dr Subotica 8, Belgrade, 11000, Serbia.
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Optimization of breast cancer excision by intraoperative ultrasound and marking needle - technique description and feasibility. World J Surg Oncol 2015. [PMID: 25896818 DOI: 10.1186/s12957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND We present a surgical technique and the preliminary results of breast cancer excision after insertion of a specially constructed marking needle into the tumor, controlled by intraoperative ultrasound. Resection margins were projected in six directions by ultrasound measurements, determined in relation to the needle, and resection was done in accordance with those measurements. The main objective was to obtain resection margins similar (equal) to those projected by intraoperative ultrasound (10 mm). METHODS Detailed description of the technique is given. Thirty-two female patients undergoing breast-conserving surgery, up to 30 mm in diameter, for palpable and non-palpable invasive breast cancer, were operated on using this technique. Its feasibility was tested by analyzing the success (rate) of needle placement in the tumor, the measurements executed, and the performance of the excision. RESULTS All stages of the technique were successfully performed to completion on all 32 patients. The procedure of needle placement and ultrasound measurement of distances took 11 min on average (between 6 and 20 min). The average distance of the tumor margin from the resection margin was 12.9 mm (2 to 30 mm, 95% confidence interval [11.9, 14.06]). There was one patient with a positive resection margin (3%). CONCLUSIONS The technique of excising palpable and non-palpable breast cancer by intraoperative ultrasound and an especially constructed marking needle is feasible and comfortable to perform. Preliminary results imply that resection volume can be rationalized, with the same or better oncological safety.
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Ballal H, Taylor DB, Bourke AG, Latham B, Saunders CM. Predictors of re-excision in wire-guided wide local excision for early breast cancer: a Western Australian multi-centre experience. ANZ J Surg 2015; 85:540-5. [PMID: 25879775 DOI: 10.1111/ans.13067] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND A significant proportion of breast cancers present as impalpable lesions requiring radiological guidance prior to surgical excision, commonly by hook-wire placement. Complete lesion excision is an essential part of treatment, and re-excision may be needed to ensure this and minimize local recurrence. We explore a 1-year audit of re-excision of hook-wire-guided excisions in two large public breast units in Western Australia and define factors associated with the requirement for re-excision. METHODS A retrospective review of wire-localized wide local excisions for early breast cancer in 2009 at two tertiary breast centres in Western Australia. RESULTS Of 148 localized lesions, 44 (30%) underwent re-excision. The only significant preoperative finding was the location of tumour in the breast. The intra-operative specimen radiograph provided useful information that influenced re-excision. Smaller (≤5 mm) and larger (>20 mm) tumours on final pathological size were more likely to undergo re-excision as well as a larger difference in actual size to predicted size. The presence of ductal carcinoma in situ (DCIS) increased re-operation, as did multifocality. CONCLUSION This study highlights factors that should make the surgeon more cautious for re-excision. Suspicion of DCIS, especially at the periphery of tumours, and a central tumour location increase risk. Lesion localization techniques play an important role in minimizing risk while maintaining cosmesis.
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Affiliation(s)
- Helen Ballal
- Breast Centre, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Donna B Taylor
- Department of Radiology, Royal Perth Hospital, Perth, Western Australia, Australia.,School of Surgery, University of Western Australia, Perth, Western Australia, Australia
| | - Anita G Bourke
- Department of Radiology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Bruce Latham
- Department of Pathology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Christobel M Saunders
- School of Surgery, University of Western Australia, Perth, Western Australia, Australia
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Ouldamer L, Lechaux E, Arbion F, Body G, Vildé A. What should be the width of radiological margin to optimize resection of non-palpable invasive or in situ ductal carcinoma? Breast 2014; 23:889-93. [PMID: 25456102 DOI: 10.1016/j.breast.2014.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 09/29/2014] [Accepted: 10/02/2014] [Indexed: 01/04/2023] Open
Abstract
PURPOSE the aim of our study was to investigate whether there is radiological margin that optimize resection of non-palpable invasive or in situ ductal carcinoma. MATERIALS AND METHODS Data were collected for all patients undergoing wire localization prior to therapeutic surgical excision between January 2010 and December 2013 at our institution. A 5 and 10-mm radiological margins were considered adequate for invasive ductal carcinoma (IDC) and in situ ductal carcinoma (DCIS) respectively. Clear histological margins were defined as no ink on the tumor for IDC and ≥2 mm for DCIS. Data were analyzed both in order to assess accuracy of the technique and in order to determine what radiological threshold should be taken. RESULTS Three hundred seventy seven women were included to the study. The radiological thresholds permitted negative histological margins in 94.7%, 60.9% and 80.9% in the pure invasive ductal carcinoma group (IDC, n = 133), the pure ductal carcinoma in situ group (DCIS, n = 92) and the mixed group (both IDC and DCIS, n = 152) respectively. In an ROC analysis evaluating the ability of radiological thresholds to obtain free pathological margins: the AUC was 0.79 (0.71-0.87, 95% confident interval, p = .0007) for Pure IDC group, 0.67 (0.57-0.87, 95% confident interval, p = .0005) for pure DCIS group, and 0.72 (0.62-0.80, 95% confident interval, p < .0001) for the mixed group. CONCLUSION We found that a radiological margin of 10 mm is needed in presence of an in situ component and 5-mm radiological margin seems enough in case of pure IDC tumors.
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Affiliation(s)
- Lobna Ouldamer
- Department of Gynecology, Centre Hospitalier Universitaire de Tours, Hôpital Bretonneau, 2 Boulevard Tonnellé, 37044 Tours, France; INSERM Unit 1069, Tours, France; François-Rabelais University, Tours, France.
| | - Emilie Lechaux
- Department of Gynecology, Centre Hospitalier Universitaire de Tours, Hôpital Bretonneau, 2 Boulevard Tonnellé, 37044 Tours, France; François-Rabelais University, Tours, France
| | - Flavie Arbion
- Department of Pathology, Centre Hospitalier Universitaire de Tours, Hôpital Bretonneau, 2 Boulevard Tonnellé, 37044 Tours, France
| | - Gilles Body
- Department of Gynecology, Centre Hospitalier Universitaire de Tours, Hôpital Bretonneau, 2 Boulevard Tonnellé, 37044 Tours, France; François-Rabelais University, Tours, France
| | - Anne Vildé
- Department of Radiology, Centre Hospitalier Universitaire de Tours, Hôpital Bretonneau, 2 Boulevard Tonnellé, 37044 Tours, France
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Haloua MH, Krekel NMA, Meijer S, van den Tol MP. Ultrasound-guided surgery for palpable breast cancer: a historical perspective. BREAST CANCER MANAGEMENT 2014. [DOI: 10.2217/bmt.14.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Breast cancer surgery has changed dramatically from the en bloc removal of the breast to the less invasive breast-conserving surgery. The recent COBALT trial comparing ultrasound-guided surgery with palpation-guided surgery for palpable breast cancer showed less margin involvement and decreased excision volumes with ultrasonography, which resulted in less additional therapy and possibly improved cosmetic outcome. Other surgical techniques pursuing these same aims have been developed over the past two decades and are referred to as oncoplastic surgery. Unfortunately oncoplastic surgery lacks sufficient evidence to corroborate its widespread implementation and should thereby solely be applied to selected cases. This review aims to highlight the position of ultrasound-guided surgery from a perspective of breast-conserving surgery in the search for better oncological and cosmetic outcomes.
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Affiliation(s)
- MH Haloua
- Department of Surgical Oncology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - NMA Krekel
- Department of Plastic & Reconstructive Surgery, VU University Medical Center, De Boelelaan 1117, Room 7F-020, 1081 HV Amsterdam, The Netherlands
| | - S Meijer
- Department of Surgical Oncology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - MP van den Tol
- Department of Surgical Oncology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
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Accuracy of ultrasound-guided breast-conserving surgery in the determination of adequate surgical margins. Breast Cancer Res Treat 2014; 145:129-36. [DOI: 10.1007/s10549-014-2932-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2014] [Accepted: 03/19/2014] [Indexed: 01/31/2023]
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Thill M. MarginProbe: intraoperative margin assessment during breast conserving surgery by using radiofrequency spectroscopy. Expert Rev Med Devices 2014; 10:301-15. [PMID: 23668703 DOI: 10.1586/erd.13.5] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
In breast conserving surgery, the tumor should be removed with a clean margin, a rim of healthy tissue surrounding. Failure to achieve clean margins in the initial surgery results in a re-excision procedure. Re-excision rates are reported as being 11-46% for invasive carcinoma and ductal carcinoma in situ (DCIS). Re-excisions can have negative consequences such as increased postoperative infections, negative impact on cosmesis, patient anxiety and increased medical costs. Therefore, the surgical margin of invasive and intraductal (DCIS) breast tissue is a subject of intense discussion. Different options for intraoperative assessment are available, but all in all, they are unsatisfying. Frozen section margin examination is possible but is time consuming and restricted to the assessment of invasive carcinoma. In the case of DCIS, there is no procedure for intraoperative margin assessment. Thus, a solution for efficient intraoperative surgical margin assessment is needed. For this purpose, an innovative, real-time, intraoperative margin-assessment device (MarginProbe, Dune Medical Devices, Caesarea, Israel) was designed, and recent published clinical data reported a reduction of re-excisions by more than 50%.
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Affiliation(s)
- Marc Thill
- Department of Gynecology and Obstetrics and Breast Cancer Center, Agaplesion Markus Hospital, Wilhelm-Epstein-Strasse 4, 60431 Frankfurt, Germany.
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Butler-Henderson K, Lee AH, Price RI, Waring K. Intraoperative assessment of margins in breast conserving therapy: a systematic review. Breast 2014; 23:112-9. [PMID: 24468464 DOI: 10.1016/j.breast.2014.01.002] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 12/14/2013] [Accepted: 01/05/2014] [Indexed: 11/28/2022] Open
Abstract
Approximately one quarter of patients undergoing breast conserving therapy for breast cancer will require a second operation to achieve adequate clearance of the margins. A number of techniques to assess margins intraoperatively have been reported. This systematic review examines current intraoperative methods for assessing margin status. The final pathology status, statistical measures including accuracy of tumour margin assessment, average time impact on the procedure and second operation rate, were used as criteria for comparison between studies. Although pathological methods, such as frozen section and imprint cytology performed well, they added on average 20-30 min to operation times. An ultrasound probe allows accurate examination of the margins and delivers results in a timely manner, yet it has a limited role with DCIS where calcification is present and in multifocal cancer. Further research is required in other intraoperative margin assessment techniques, such as mammography, radiofrequency spectroscopy and optical coherence tomography.
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Affiliation(s)
- Kerryn Butler-Henderson
- School of Public Health, Curtin University, GPO Box U1987, Perth, Western Australia 6845, Australia.
| | - Andy H Lee
- School of Public Health, Curtin University, GPO Box U1987, Perth, Western Australia 6845, Australia.
| | - Roger I Price
- Medical Technology & Physics, Sir Charles Gairdner Hospital, Nedlands, Western Australia 6009, Australia; School of Physics, University of Western Australia, Nedlands, Western Australia 6009, Australia.
| | - Kaylene Waring
- Patient Information Service, Armadale Health Service, PO Box 460, Armadale, Western Australia 6992, Australia.
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The role of intraoperative ultrasound in breast-conserving surgery of nonpalpable breast cancer. Wien Klin Wochenschr 2014; 126:90-4. [PMID: 24442857 DOI: 10.1007/s00508-013-0470-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 11/06/2013] [Indexed: 12/20/2022]
Abstract
OBJECTIVE This retrospective study was undertaken to evaluate the role of intraoperative ultrasound in breast-conserving surgery of nonpalpable breast cancer. METHODS The data about 125 patients with preoperatively diagnosed breast cancer operated with the help of intraoperative ultrasound between January 2009 and December 2012 were retrospectively analyzed. RESULTS The mean volume of the excised tissue was 42.1 cm(3) (± 22.0 cm(3)). Immediate re-excision after ultrasound examination of the excised tissue was performed in 27 patients (21.6 %). Secondary procedure owing to positive histological margins was necessary only in four patients (3.2 %). CONCLUSIONS Intraoperative ultrasound offers some advantages in comparison with other localization techniques for nonpalpable breast cancer surgery.
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Scolaro L, McLaughlin RA, Kennedy BF, Saunders CM, Sampson DD. A review of optical coherence tomography in breast cancer. ACTA ACUST UNITED AC 2014. [DOI: 10.1515/plm-2014-0013] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AbstractOptical coherence tomography (OCT) is a medical imaging modality that opens up new opportunities for imaging in breast cancer. It provides two- and three-dimensional micro-scale images of tissue structure from bulk tissue,
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Abstract
Ultrasonography (US) is an indispensable tool in breast imaging and is complementary to both mammography and magnetic resonance (MR) imaging of the breast. Advances in US technology allow confident characterization of not only benign cysts but also benign and malignant solid masses. Knowledge and understanding of current and emerging US technology, along with the application of meticulous scanning technique, is imperative for image optimization and diagnosis. The ability to synthesize breast US findings with multiple imaging modalities and clinical information is also necessary to ensure the best patient care. US is routinely used to guide breast biopsies and is also emerging as a supplemental screening tool in women with dense breasts and a negative mammogram. This review provides a summary of current state-of-the-art US technology, including elastography, and applications of US in clinical practice as an adjuvant technique to mammography, MR imaging, and the clinical breast examination. The use of breast US for screening, preoperative staging for breast cancer, and breast intervention will also be discussed.
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Affiliation(s)
- Regina J Hooley
- Department of Diagnostic Radiology, Yale University School of Medicine, 333 Cedar St, PO Box 208042, New Haven, CT 06520-8042, USA.
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Eggemann H, Ignatov T, Beni A, Costa SD, Ignatov A. Ultrasonography-guided breast-conserving surgery is superior to palpation-guided surgery for palpable breast cancer. Clin Breast Cancer 2013; 14:40-5. [PMID: 24169374 DOI: 10.1016/j.clbc.2013.08.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2013] [Revised: 08/27/2013] [Accepted: 08/28/2013] [Indexed: 01/27/2023]
Abstract
INTRODUCTION The aim of this study was to determine the efficacy of ultrasonography (US)-guided excision of palpable breast cancer and to compare it with the standard palpation-guided breast-conserving surgery (BCS). METHODS For this purpose, 335 women with palpable breast cancer who underwent BCS were retrospectively studied. The positive surgical margins and re-excision rates were investigated. RESULTS Of the total cohort, 137 patients were treated with palpation-guided BCS and 198 underwent US-guided tumor excision. The tumor and patient characteristics were similar in both groups. Patient age, postmenopausal status, tumor size, histological grade, intraductal tumor component, lobular histology, and palpation-guided tumor excision were associated with increased risk of positive margins. The shave margins were re-excised at the time of original operation more often by palpation-guided localization (28.5%) than by the US-guided procedure (11.1%) (P < .0001). A surgeon was able to correctly identify the "problematic" margin in 81.1% of cases via intraoperative US and in only 17.9% via palpation (P < .0001). The re-excision rate during a second operation was significantly reduced by US-guided tumorectomy (P = .004). Of 198 patients in the US-guided group, 23 (11.6%) underwent a second operation, as did 33 of 137 patients in the palpation group (24.1%). The sensitivity and specificity of US-guided excisions were 52.7% and 97.5%, respectively, whereas the sensitivity and the specificity of palpation-guided tumor excisions were 15.5% and 65.9%, respectively. CONCLUSION US-guided BCS is superior to palpation-guided excision in predicting the closest margins, obtaining clear surgical margins, and reducing re-operations.
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Affiliation(s)
- Holm Eggemann
- Department of Obstetrics and Gynecology, University Clinic Magdeburg, Magdeburg, Germany
| | - Tanja Ignatov
- Department of Obstetrics and Gynecology, University Clinic Magdeburg, Magdeburg, Germany
| | - Alexander Beni
- Department of Obstetrics and Gynecology, University Clinic Magdeburg, Magdeburg, Germany
| | - Serban Dan Costa
- Department of Obstetrics and Gynecology, University Clinic Magdeburg, Magdeburg, Germany
| | - Atanas Ignatov
- Department of Obstetrics and Gynecology, University Clinic Magdeburg, Magdeburg, Germany; Department of Obstetrics and Gynecology, University Medical Center Regensburg, Regensburg, Germany.
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Los márgenes de resección en la cirugía conservadora del cáncer de mama. Cir Esp 2013; 91:404-12. [DOI: 10.1016/j.ciresp.2013.02.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Revised: 02/07/2013] [Accepted: 02/21/2013] [Indexed: 11/19/2022]
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Yu CC, Chiang KC, Kuo WL, Shen SC, Lo YF, Chen SC. Low re-excision rate for positive margins in patients treated with ultrasound-guided breast-conserving surgery. Breast 2013; 22:698-702. [PMID: 23333255 DOI: 10.1016/j.breast.2012.12.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Revised: 11/28/2012] [Accepted: 12/26/2012] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Re-excision is a necessary procedure in obtaining clean margins for breast-conserving surgery (BCS)-treated patients. Re-excision rates vary widely among different breast cancer management procedures. The aim of this study was to evaluate the efficacy of ultrasound (US)-guided BCS to decrease the re-excision rate in patients with US-detectable breast cancer, as well as the relationship between positive margins and ultrasonographic characteristics of tumor. METHODS Between 2008 and 2009, we identified consecutive patients who underwent initial US-guided BCS for breast in situ or invasive carcinoma, which was preoperatively detected using US examination and on the basis of image-guided biopsy findings. The margins achieved after BCS were separately assessed by performing frozen section analysis of shaved margins. The negative margin and positive margin groups were compared for clinicopathological features and ultrasonographic findings. RESULTS Of 381 patients undergoing US-guided BCS, 126 (33.1%) had palpable tumors and 255 (66.9%) had nonpalpable tumors. Positive margins were noted in 35 patients (9.2%). These patients underwent re-excision and were margin-free; no further surgery was required for these patients. There were no significant intergroup differences in clinicopathological features and ultrasonographic findings. CONCLUSION Breast US is an effective modality for intraoperative tumor localization and can thus help obtain clean margins and reduce the re-excision rate in cases in which breast-conserving therapy has been performed. Furthermore, frozen section analysis of cavity shaved margins is a feasible method for minimizing the need for further surgery.
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Affiliation(s)
- Chi-Chang Yu
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University Medical College, Taoyuan, Taiwan
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Krekel NMA, Haloua MH, Lopes Cardozo AMF, de Wit RH, Bosch AM, de Widt-Levert LM, Muller S, van der Veen H, Bergers E, de Lange de Klerk ESM, Meijer S, van den Tol MP. Intraoperative ultrasound guidance for palpable breast cancer excision (COBALT trial): a multicentre, randomised controlled trial. Lancet Oncol 2012; 14:48-54. [PMID: 23218662 DOI: 10.1016/s1470-2045(12)70527-2] [Citation(s) in RCA: 130] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Breast-conserving surgery for palpable breast cancer is associated with tumour-involved margins in up to 41% of cases and excessively large excision volumes. Ultrasound-guided surgery has the potential to resolve both of these problems, thereby improving surgical accuracy for palpable breast cancer. We aimed to compare ultrasound-guided surgery with the standard for palpable breast cancer-palpation-guided surgery-with respect to margin status and extent of healthy breast tissue resection. METHODS In this randomised controlled trial, patients with palpable T1-T2 invasive breast cancer were recruited from six medical centres in the Netherlands between October, 2010, and March, 2012. Eligible participants were randomly assigned to either ultrasound-guided surgery or palpation-guided surgery in a 1:1 ratio via a computer-generated random sequence and were stratified by study centre. Patients and investigators were aware of treatment assignments. Primary outcomes were surgical margin involvement, need for additional treatment, and excess healthy tissue resection (defined with a calculated resection ratio derived from excision volume and tumour diameter). Data were analysed by intention to treat. This trial is registered at http://www.TrialRegister.nl, number NTR2579. FINDINGS 134 patients were eligible for random allocation. Two (3%) of 65 patients allocated ultrasound-guided surgery had tumour-involved margins compared with 12 (17%) of 69 who were assigned palpation-guided surgery (difference 14%, 95% CI 4-25; p=0·0093). Seven (11%) patients who received ultrasound-guided surgery and 19 (28%) of those who received palpation-guided surgery required additional treatment (17%, 3-30; p=0·015). Ultrasound-guided surgery also resulted in smaller excision volumes (38 [SD 26] vs 57 [41] cm(3); difference 19 cm(3), 95% CI 7-31; p=0·002) and a reduced calculated resection ratio (1·0 [SD 0·5] vs 1·7 [1·2]; difference 0·7, 95% CI 0·4-1·0; p=0·0001) compared with palpation-guided surgery. INTERPRETATION Compared with palpation-guided surgery, ultrasound-guided surgery can significantly lower the proportion of tumour-involved resection margins, thus reducing the need for re-excision, mastectomy, and radiotherapy boost. By achieving optimum resection volumes, ultrasound-guided surgery reduces unnecessary resection of healthy breast tissue and could contribute to improved cosmetic results and quality of life. FUNDING Dutch Pink Ribbon Foundation, Osinga-Kluis Foundation, Toshiba Medical Systems.
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Affiliation(s)
- Nicole M A Krekel
- Department of Surgical Oncology, VU University Medical Center, Amsterdam, Netherlands
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Atkins J, Al Mushawah F, Appleton CM, Cyr AE, Gillanders WE, Aft RL, Eberlein TJ, Gao F, Margenthaler JA. Positive margin rates following breast-conserving surgery for stage I-III breast cancer: palpable versus nonpalpable tumors. J Surg Res 2012; 177:109-15. [PMID: 22516344 DOI: 10.1016/j.jss.2012.03.045] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2011] [Revised: 03/08/2012] [Accepted: 03/22/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND Margin status is a significant risk factor for local recurrence. We sought to examine whether the method of tumor localization predicted the margin status and the need for re-excision for both nonpalpable and palpable breast cancer. METHODS We identified 358 consecutive breast cancer patients who were treated with breast-conserving therapy (BCT) from 1999 to 2006. Data included patient and tumor characteristics, method of localization (needle versus palpation), and pathologic outcomes. Descriptive statistics were used for data summary and data were compared using χ(2). RESULTS Of 358 patients undergoing BCT, 234 (65%) underwent needle localization for a nonpalpable tumor and 124 (35%) underwent a palpation-guided procedure. Patients undergoing palpation-guided procedures were younger and had larger tumors at a more advanced pathologic stage of disease than those undergoing needle localization procedures (P < 0.05 for each). Patient race, tumor grade, presence of lymphovascular invasion, biomarker profile, and nodal status were not significantly different between the two groups (P > 0.05). Overall, 137 patients (38%) had one or more positive margins: 90 of 234 (38%) who had a needle localization procedure and 47 of 124 (38%) who had a palpation-guided procedure (P > 0.05). The number of margins affected did not differ significantly between the two groups. CONCLUSION Although patients with palpable breast cancer had larger tumors than those with nonpalpable breast cancer, the incidence and number of positive margins was similar to those who had needle localization for nonpalpable tumors. Improved methods of localization are needed to reduce the rate of positive margins and the need for re-excision.
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Affiliation(s)
- Jordan Atkins
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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Doyle TE, Factor RE, Ellefson CL, Sorensen KM, Ambrose BJ, Goodrich JB, Hart VP, Jensen SC, Patel H, Neumayer LA. High-frequency ultrasound for intraoperative margin assessments in breast conservation surgery: a feasibility study. BMC Cancer 2011; 11:444. [PMID: 21992187 PMCID: PMC3209468 DOI: 10.1186/1471-2407-11-444] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2011] [Accepted: 10/12/2011] [Indexed: 12/22/2022] Open
Abstract
Background In addition to breast imaging, ultrasound offers the potential for characterizing and distinguishing between benign and malignant breast tissues due to their different microstructures and material properties. The aim of this study was to determine if high-frequency ultrasound (20-80 MHz) can provide pathology sensitive measurements for the ex vivo detection of cancer in margins during breast conservation surgery. Methods Ultrasonic tests were performed on resected margins and other tissues obtained from 17 patients, resulting in 34 specimens that were classified into 15 pathology categories. Pulse-echo and through-transmission measurements were acquired from a total of 57 sites on the specimens using two single-element 50-MHz transducers. Ultrasonic attenuation and sound speed were obtained from time-domain waveforms. The waveforms were further processed with fast Fourier transforms to provide ultrasonic spectra and cepstra. The ultrasonic measurements and pathology types were analyzed for correlations. The specimens were additionally re-classified into five pathology types to determine specificity and sensitivity values. Results The density of peaks in the ultrasonic spectra, a measure of spectral structure, showed significantly higher values for carcinomas and precancerous pathologies such as atypical ductal hyperplasia than for normal tissue. The slopes of the cepstra for non-malignant pathologies displayed significantly greater values that differentiated them from the normal and malignant tissues. The attenuation coefficients were sensitive to fat necrosis, fibroadenoma, and invasive lobular carcinoma. Specificities and sensitivities for differentiating pathologies from normal tissue were 100% and 86% for lobular carcinomas, 100% and 74% for ductal carcinomas, 80% and 82% for benign pathologies, and 80% and 100% for fat necrosis and adenomas. Specificities and sensitivities were also determined for differentiating each pathology type from the other four using a multivariate analysis. The results yielded specificities and sensitivities of 85% and 86% for lobular carcinomas, 85% and 74% for ductal carcinomas, 100% and 61% for benign pathologies, 84% and 100% for fat necrosis and adenomas, and 98% and 80% for normal tissue. Conclusions Results from high-frequency ultrasonic measurements of human breast tissue specimens indicate that characteristics in the ultrasonic attenuation, spectra, and cepstra can be used to differentiate between normal, benign, and malignant breast pathologies.
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Affiliation(s)
- Timothy E Doyle
- Department of Physics, Utah Valley University, Orem, UT 84058, USA.
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Fisher CS, Mushawah FA, Cyr AE, Gao F, Margenthaler JA. Ultrasound-guided lumpectomy for palpable breast cancers. Ann Surg Oncol 2011; 18:3198-203. [PMID: 21861232 DOI: 10.1245/s10434-011-1958-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2011] [Indexed: 12/22/2022]
Abstract
BACKGROUND We sought to determine the re-excision rate following lumpectomy for palpable breast cancers using intraoperative ultrasound (US). A secondary aim was to investigate the impact on surgical decision-making. METHODS We identified 73 women who underwent US-guided lumpectomy for palpable breast cancer between 2006 and 2010. A cohort of 124 women who underwent palpation-guided lumpectomy was used for a comparison group. Data included patient demographics, tumor characteristics, intraoperative findings, and pathologic outcomes. Descriptive statistics were used for data summary and compared by chi-square or t test, as appropriate. RESULTS A total of 73 women underwent US-guided lumpectomy, and 124 women underwent palpation-guided lumpectomy (median age 55 years). Patients undergoing palpation-guided lumpectomy had smaller tumors that were more likely to be HER2/neu amplified compared with patients undergoing US-guided lumpectomy (P < 0.05 for each). There were no differences between the 2 groups with respect to patient age, tumor grade, and estrogen/progesterone receptor status (P > 0.05 for each). Re-excision rates were similar in both groups [17 (23%) in the US group versus 31 (25%) in the palpation group; P > 0.05]. In the US group, 45 patients (62%) had additional shave margins taken based on US interrogation of the specimen, and 12 patients (16%) were spared a 2nd procedure based on the use of intraoperative US. CONCLUSIONS Although palpable breast cancers can be excised based on direct palpation or needle localization, we believe that US guidance provides an excellent tool to aid the breast surgeon. Only 10% of patients had a positive margin on final pathology as a result, and the overall re-excision rate was acceptable.
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Affiliation(s)
- Carla S Fisher
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
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