Abstract
The increasing number of breast cancer survivors and their longevity has emphasized the importance of esthetic and functional outcomes of cancer surgery and increased pressure for the surgical treatment to achieve negative margins with minimal removal of healthy tissue. Surgical smoke has been successfully utilized in tissue identification in laboratory conditions by using a system based on differential mobility spectrometry (DMS) that could provide a seamless margin assessment method. In this study, a DMS-based tissue analysis system was used intraoperatively in 20 breast cancer surgeries to assess its feasibility in tissue identification. The effect of the system on complications and duration of surgeries was also studied. The surgeries were recorded with a head-worn camera system for visual annotation of the operated tissue types to enable classification of the measurement files by supervised learning. There were statistically significant differences among the DMS spectra of the tissue types. The classification of four tissue types (skin, fat, glandular tissue, and connective tissue) yielded a cross-validated accuracy of 44% and exhibited high variation between surgeries. The low accuracies can be attributed to the limitations and uncertainty of the visual annotation, high-within class variance due to the heterogeneity of tissues as well as environmental conditions, and delays of the real-time analysis of the smoke samples. Differences between tissues encountered in breast surgery were identified and the technology can be implemented in surgery workflow. However, in its current state, the DMS-based system is not yet applicable to a clinical setting to aid in margin assessment.
Highlights
Breast cancer is the most common cancer affecting more than two million women worldwide annually [1]
Four patients (20%) underwent lumpectomy, ten patients (50%) level 1 oncoplastic breast conserving surgery, one patient (5%) oncoplastic breast conserving surgery combined with reduction mammoplasty of the healthy breast, and five patients (25%) oncoplastic reduction mammoplasty combined with reduction mammoplasty of the healthy breast
One patient had a diagnosis of 2 mm pleomorphic lobular carcinoma in situ (LCIS) on final histopathological analysis, preoperative diagnosis had been ductal carcinoma in situ (DCIS) grade 3, and smallest lateral 1 mm margin was accepted
Summary
Breast cancer is the most common cancer affecting more than two million women worldwide annually [1]. As tumors are found earlier and smaller, and larger tumors may be operated utilizing oncoplastic methods, more patients are likely to receive breast conserving therapy, a combination of breast conserving surgery (BCS) and whole breast irradiation to eradicate any microscopic residual disease. A negative margin is defined as no ink on tumor for invasive carcinoma and 2 mm histological margin for ductal carcinoma in situ (intraductal carcinoma, DCIS) [8]– [11]. Positive histological margin increases the risk of local recurrence [11] and reoperation is recommended to obtain negative margins. Reoperations may worsen the prognosis by delaying adjuvant therapy [19], cause psychological stress and may impair the cosmetics [20], and are associated with higher incidence of post-operative wound complications [21] and increased economic burden [22]. Patients with smaller excision volumes have improved cosmetic outcomes compared to larger excision volumes [20], [23]
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