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

Benedikt Schaefgen,Fabian Riedel,André Pfob,Michael Golatta,Thomas Bruckner,Annika Funk,Christina Gomez,Jörg Heil,Aba Harcos,H.-P Sinn,André Hennigs,Johanna Hederer,Juliane Nees,Sarah Fastner,Christof Sohn,Annabelle Haller,Riku Togawa,Anne Stieber

doi:10.1007/s10549-021-06466-3

Abstract

PurposeThis is the first study to systematically evaluate the diagnostic accuracy of intraoperative specimen radiography on margin level and its potential to reduce second surgeries in patients treated with neoadjuvant chemotherapy.MethodsThis retrospective study included 174 cases receiving breast conserving surgery (BCS) after neoadjuvant chemotherapy (NACT) of primary breast cancer. Conventional specimen radiography (CSR) was performed to assess potential margin infiltration and recommend an intraoperative re-excision of any radiologically positive margin. The histological workup of the specimen served as gold standard for the evaluation of the accuracy of CSR and the potential reduction of second surgeries by CSR-guided re-excisions.Results1044 margins were assessed. Of 47 (4.5%) histopathological positive margins, CSR identified 9 correctly (true positive). 38 infiltrated margins were missed (false negative). This resulted in a sensitivity of 19.2%, a specificity of 89.2%, a positive predictive value (PPV) of 7.7%, and a negative predictive value (NPV) of 95.9%. The rate of secondary procedures was reduced from 23 to 16 with a number needed to treat (NNT) of CSR-guided intraoperative re-excisions of 25.In the subgroup of patients with cCR, the prevalence of positive margins was 10/510 (2.0%), PPV was 1.9%, and the NNT was 85.ConclusionPositive margins after NACT are rare and CSR has only a low sensitivity to detect them. Thus, the rate of secondary surgeries cannot be significantly reduced by recommending targeted re-excisions, especially in cases with cCR. In summary, CSR after NACT is inadequate for intraoperative margin assessment but remains useful to document removal of the biopsy site clip.

Highlights

In the past decades, breast conserving surgery (BCS) has become the standard surgical approach for early breast cancer, and leads to equal [1, 2] or superior [3, 4] overall survival compared to mastectomy
The prevalence of initially positive margins is expected to be lower in patients after Neoadjuvant chemotherapy (NACT) and the use of Conventional specimen radiography (CSR) seems questionable in the postneoadjuvant setting [15]
We found a similar specificity (86.8%, versus 89.8%, p = 0.055), but a significantly lower sensitivity (19.2%) in the NACT cohort compared to the non-NACT cohort (36.8%; p = 0.012)

Summary

Introduction

Breast conserving surgery (BCS) has become the standard surgical approach for early breast cancer, and leads to equal [1, 2] or superior [3, 4] overall survival compared to mastectomy. Neoadjuvant chemotherapy (NACT) is the standard approach for high-risk cancer patients and can lead to a significant reduction of tumor mass. Often this allows a further reduction of the extent of breast surgeries, which contributes to an improvement of. Conventional specimen radiography (CSR) using mammography in two orthogonal orientations is used to assess the margin status and recommend intraoperative re-excision if necessary. This leads to tumor free resection margins and can help to avoid a secondary re-excision. The prevalence of initially positive margins is expected to be lower in patients after NACT and the use of CSR seems questionable in the postneoadjuvant setting [15]

Methods

Results

Discussion

Conclusion