Cavity Shave Research Articles

Intraoperative flow cytometry for invasive breast cancer conserving surgery: A new alternative or adjunct to cavity shaving technique?

Intraoperative flow cytometry for invasive breast cancer conserving surgery: A new alternative or adjunct to cavity shaving technique?

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

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

TP8.1.10 Factors predicting residual disease on re-excision after breast conserving surgery

Abstract Introduction Breast conserving surgery is the standard of care for early breast cancer, however in a quarter of patients, satisfactory margins are not achieved, usually leading to re-excision. Residual disease is found in less than half of these re-excisions, leading to increased morbidity,poorer cosmesis and increased cost with no oncological benefit. Our study aimed to identify a group of patients with unsatisfactory margins but a low risk of residual disease, who may be able to avoid re-excision. Methods All patients from our unit undergoing re-excision for unsatisfactory margins after breast conserving surgery between January 2013 and October 2019 were identified. Pathological factors predicting residual disease were investigated using univariable and multivariable analysis. Results 220 patients were included. 90 (41%) had residual disease in the re-excision specimen. Residual disease was more likely in those having mastectomy than cavity shaves (61% vs 32%, p &amp;lt; 0.0001). Residual disease increased in a linear fashion with number of involved margins and with increasing tumour size. Tumour size &amp;lt;20mm (p = 0.045), a pathological to radiological tumour size ratio less than 1.5 (p &amp;lt; 0.0001) and disease-free cavity shaves taken at initial surgery (p = 0.041) were all significant predictors of a low chance of residual disease on multivariable analysis. Patients with all three factors had a 14% chance of residual disease. Conclusions More than half of patients undergo unnecessary re-excision, and patients with small, radiologically obvious tumours are less likely to have residual disease. The decision on re-excision should include these factors in addition to the margin status.

Routine Margin Shaving Of Lumpectomy Cavity During Breast Conserving Surgery Detects Occult Multifocal Cancer, A Prospective Study

Background: Cavity shaving (CS) entails circumferential tissue removal from residual lumpectomy cavity following tumor resection during breast conserving surgery (BCS). It could allow detection of occult multifocal breast cancer (OMFBC). Objectives: This study aimed to highlight the impact of unidentified OMFBC as essential risk factor for local recurrence after BCS. Patients and Methods: Eligible breast cancer patients for BCS and CS were prospectively enrolled. Patients with negative margins of “resected tumor specimens” were designated as group A whereas group B comprised those with positive margins. OMFBC, diagnosed in the additionally shaved margins of the “residual lumpectomy cavity” as malignant breast tissues with intervening normal areas, was investigated in both groups. The study was conducted through the period from November, 2017 to March, 2021. Results: Forty-two patients with median age of 43 years were studied. Group A included 32 patients (76.2%) compared with 10 (23.8%) in group B. Overall, OMFBC was confirmed in the additionally shaved margins in 6 (14.3%) patients. OMFBC rate was less in group A (4/32 patients, 12.5%) compared to B (2/10 patient, 20%), however the difference did not reach statistical significance. In group B, another 1 patient showed persistent positive margins without evidence of OMFBC. All 7 patients with positive CS margins (6 with OMFBC and 1 with persistent positive margin without evidence of OMFBC) had their treatment strategy switched to modified radical mastectomy. Local recurrence occurred in only one among the remaing 35 patients (2.9%) who were treated by BCS with CS. Conclusions: CS improves outcome of BCS by reducing the rate of positive margins, enabling diagnosis of occult multifocal breast cancer and reducing local recurrence.

Factors predicting residual disease on re-excision after breast conserving surgery

IntroductionBreast conserving surgery is the standard of care for early breast cancer, however in a quarter of patients, satisfactory margins are not achieved, usually leading to re-excision. Residual disease is found in less than half of these re-excisions, leading to increased morbidity, poorer cosmesis and increased cost, possibly with no oncological benefit. Our study aimed to identify a group of patients with unsatisfactory margins but a low risk of residual disease, who may be able to avoid re-excision. Methods and materialsAll patients from our unit undergoing re-excision for unsatisfactory margins after breast conserving surgery between January 2013 and October 2019 were identified. Pathological factors predicting residual disease were investigated using univariable and multivariable analysis. Results220 patients were included. 90 (41 %) had residual disease. Residual disease was more likely in those having mastectomy than cavity shaves (61 % vs 32 %, p < 0.0001). Residual disease increased in a linear fashion with number of involved margins and with increasing tumour size. Tumour size <20 mm (p = 0.045), a pathological to radiological tumour size ratio less than 1.5 (p < 0.0001) and disease-free cavity shaves taken at initial surgery (p = 0.041) were all independent predictors of a low chance of residual disease on multivariable analysis. Patients with all three factors had a 14 % chance of residual disease. ConclusionsMore than half of patients undergo potentially unnecessary re-excision, and patients with small, radiologically obvious tumours are less likely to have residual disease. The decision on re-excision should include these factors in addition to the margin status.

Cavity shaving for invasive breast cancer conservative surgery: Reduced specimen volume and margin positive rates

IntroductionThe cavity shaving (CS) technique was described in breast conserving surgery to reduce the rate of reoperation avoiding the need for intraoperative margin analysis. This study assesses differences in the rates of involvement of the surgical margin (requiring further surgery) and volume of surgical specimens, depending on the use or not of this technique. Material and methodsA retrospective cohort study was conducted in patients with breast carcinoma who underwent breast conserving surgery between 2013 and 2019. They were divided into two groups depending on whether the cavity shaving technique was used or not. Primary outcomes of the study included presence of final margin involvement, requiring need for further surgery, and the volume of excised tissue comparing the study groups. ResultsA total of 202 cases were included: 92 in the control group and 110 in the cavity shaving group. Significant differences were found regarding involvement of the final margin (19.57% control group vs. 4.55% cavity shaving group; p = 0.010). The volume of additional surgical specimens were significantly greater in the traditional technique group than in the shaving technique (46.43 vs 13.32 cm3; p = 0.01) as was total specimen volume (143.40 vs 100.63 cm3; p = 0.022). ConclusionsCS can reduce the positive margin and re-excision rates without larger-volume resections and should therefore be considered a routine technique in BCS for early-stage breast cancer.

The Effect of Lumpectomy and Cavity Shave Margin Status on Recurrence and Survival in Breast-Conserving Surgery.

Cavity shave margins (CSMs) decrease rate of positive margins and need for re-excision. Recurrence data following breast-conserving surgery (BCS) are not always available in large cancer registries. We sought to define our recurrence and survival data in BCS with routine excision of CSMs. A single institution, 10-year retrospective review of breast cancer patients who underwent BCS with routine CSMs was conducted. Cavity shave margin technique was standard. Cox proportional hazard analyses and the Kaplan-Meier method were used to estimate recurrence and survival. Breast-conserving surgery with CSM was performed in 839 patients. Re-excision rate to achieve negative margins was 8.5%. Fifty-two patients (75%) underwent margin re-excision vs 18 patients (25%) underwent salvage mastectomy. Positive margin rate stratified by tumor histology was highest for invasive lobular carcinoma followed by mixed invasive ductal carcinoma (IDC) and ductal carcinoma in situ (DCIS), followed by pure DCIS and lowest for IDC. Length of follow-up was (4.7 ± 2.6, years). Overall recurrence rate (locoregional and systemic) was 4.3%: highest in patients with negative lumpectomy margin but positive CSM (L-S+ = 15%) followed by positive lumpectomy and CSMs (L+S+ = 14%), followed by patients with positive lumpectomy margin but negative CSMs (L+S- = 13%) and lowest for negative lumpectomy and CSM (L-S- = 5%), (P = .0008). There was no difference in 5-year breast cancer-specific survival between the 4 subgroups: 96% for L-S-, 86.7% L-S+, 94.7% L+S+ and 90% L+S- (P = .094). Recurrence following BCS with CSMs can be stratified based on both lumpectomy and cavity shave margin positivity. Routine excision of CSMs allows identification of these patient subsets.

Multi-magnification-based machine learning as an ancillary tool for the pathologic assessment of shaved margins for breast carcinoma lumpectomy specimens.

The surgical margin status of breast lumpectomy specimens for invasive carcinoma and ductal carcinoma in situ (DCIS) guides clinical decisions, as positive margins are associated with higher rates of local recurrence. The "cavity shave" method of margin assessment has the benefits of allowing the surgeon to orient shaved margins intraoperatively and the pathologist to assess one inked margin per specimen. We studied whether a deep convolutional neural network, a deep multi-magnification network (DMMN), could accurately segment carcinoma from benign tissue in whole slide images (WSIs) of shave margin slides, and therefore serve as a potential screening tool to improve the efficiency of microscopic evaluation of these specimens. Applying the pretrained DMMN model, or the initial model, to a validation set of 408 WSIs (348 benign, 60 with carcinoma) achieved an area under the curve (AUC) of 0.941. After additional manual annotations and fine-tuning of the model, the updated model achieved an AUC of 0.968 with sensitivity set at 100% and corresponding specificity of 78%. We applied the initial model and updated model to a testing set of 427 WSIs (374 benign, 53 with carcinoma) which showed AUC values of 0.900 and 0.927, respectively. Using the pixel classification threshold selected from the validation set, the model achieved a sensitivity of 92% and specificity of 78%. The four false-negative classifications resulted from two small foci of DCIS (1 mm, 0.5 mm) and two foci of well-differentiated invasive carcinoma (3 mm, 1.5 mm). This proof-of-principle study demonstrates that a DMMN machine learning model can segment invasive carcinoma and DCIS in surgical margin specimens with high accuracy and has the potential to be used as a screening tool for pathologic assessment of these specimens.

Identification of a localization wire tip in an occult breast lesion using a handheld magnetometer.

The Sentimag hand-held probe detects the magnetic response from iron oxide particles trapped in a sentinel node. To investigate if an electromagnetic probe can be helpful in the identification of a hook wire tip located in an occult breast lesion. Forty-two patients undergoing lumpectomy without axillary procedure were enrolled. In all cases, suspicious non-palpable microcalcifications without mass were found, and a vacuum-assisted stereotactic biopsy was performed. On the day of surgery, a traditional localization wire (LW) was placed under imaging guidance. The Sentimag magnetometer was used to precisely detect the wire tip through the skin. Then, the skin incision was made and Sentimag was used again to guide the surgeon to the lumpectomy bed. The accuracy of excision was assessed with intra-operative specimen 3D tomosynthesis. Median lesion size was 16 mm (range: 4-38 mm) and median depth was 33 mm (range: 14-78 mm). In all cases, the wire tip was successfully identified. Neither wire displacement nor transection occurred. Intraoperative radiography demonstrated doubtful margin requiring selective cavity shaving in 6 patients (14%). The need for cavity shaving was significantly influenced by the lesion size and histology: median size 30 mm (range: 24-38 mm) compared to 15 mm (range: 4-28 mm) and histology of ductal carcinoma in situ (DCIS) compared to atypical ductal hyperplasia (ADH) and lobular neoplasia (LN). Tumors requiring cavity shaving tended to be deeper - they had a median depth of 43 mm (range: 17-78 mm) compared to 32 mm (range: 14-76 mm) in patients who did not need cavity shaving, but this parameter was statistically significant. Intraoperative identification of the wire tip using Sentimag is a simple technique facilitating targeted excision without excessive removal of breast tissue. Since it is not associated with additional costs, it may be worth considering, particularly in developing countries.

Breast-Conserving Surgeries With and Without Cavity Shave Margins Have Different Re-excision Rates and Associated Overall Cost: Institutional and Patient-Driven Decisions for Its Utilization

BackgroundReducing the rate of margin positivity and reoperations remains a paramount goal in breast-conserving surgery (BCS). This study assesses the effectiveness of standard partial mastectomy with cavity shave margins (CSM) compared with partial mastectomy with selective margin resection (SPM), with regard to outcomes of the initial surgeries, re-excisions, and overall costs. Patients and MethodsThis is a retrospective review of 122 eligible breast cancer patients who underwent BCS at one institution. The CSM and SPM groups each included 61 patients, matched for presurgical diagnoses and clinical stage. Data including margin status, rates and reason for re-excision, associated operation times, and costs were analyzed. ResultsPatients undergoing CSM had less than half the rate of positive margins (PMs) (10% vs. 23%; P = .03) and re-excisions (8% vs. 23%; P = .02) compared with SPM. In the former group, the margin involvement was focal, and re-excisions were performed almost exclusively for PMs. For SPM, the majority (92%) of PMs were on the main lumpectomy specimen rather than the selective margins, and re-excisions included, in addition to PMs, extensive or multifocal negative but close margins. Reduced breast tissue volumes were removed with CSM, particularly for patients undergoing a single surgery (47 vs. 165 cm3; P < .001). The initial surgery with CSM is on average 27% more costly than that for SPM (P < .001), due to the increased pathology costs which are partially offset by the increased re-excision rates in SPM. ConclusionCircumferential cavity shaving, associated with consistent lower PMs, tissue volumes excised, and re-excision rates, is appropriate for routine implementation as a method offering superior surgical outcomes.

Abstract PS1-34: Oncological safety and patient journey with magseed™ localised breast conserving surgery

Abstract Introduction: Wire localised wide local excision (W-WLE) has been the standard of care for impalpable breast lesions and requires insertion of the wire on the same day as the surgery. Logistics of same day localisation can lead to a chaotic morning for the patients with long uncomfortable waiting times prior to their surgery. Transporting patients across the hospital and at times between different sites can add to poor patient experience and inefficient theatre utilisation. Magseed localised wide local excision (M-WLE) is an alternative to W-WLE. Magseed is a 5mm non-radioactive paramagnetic seed inserted radiologically and in the UK it is licensed for insertion up to 30 days in advance. M-WLE was started for routine use in our Unit in July 2019. We compare the safety parameters and length of hospital stay (LOS) in patients undergoing M-WLE to W-WLE. Methods: All M-WLEs performed at a single institution over an 8 month period (Jul 19 - Feb 20) were included. These were compared to a historic matched cohort of W-WLEs performed over 8 months (Jan 18 - Aug 18) which would have been suitable for Magseed localisation. The suitability for Magseed localisation was decided by a breast radiologist based on local objective criteria. Intra-operative cavity shaves were performed based on specimen X-ray and re-excisions were performed where there was tumour at or &amp;lt; 1 mm from inked margin. Exclusion criteria for Magseed localisations included - i. multiple lesions requiring 2 or more wires and ii. Depth of lesion from skin (&amp;gt;3cm on ultrasound or &amp;gt;7cm deep in central breast on mammogram). Data including patient demographics, type of localisation, successful placements, pathology, re-excision rates, tumour size, and length of stay (LOS) was collected and analysed. Results: Over the 16 months, 319 patients underwent localised WLEs. 238 patients were included in the study and 81 excluded. Patient demographics and tumour characteristics are detailed in Table 1. There is no significant difference in the intra-operative cavity shaves between the two groups. A significant difference in the re-excisions rates favouring the M-WLE group despite no significant difference in the mean tumour to specimen ratio was seen. (Table 2) The median waiting time to surgery from the time of admission was observed to be significantly shorter in the M-WLE group (4h15mins vs 7h03mins, p&amp;lt;0.01). There was no significant difference in the median LOS between the two groups (M-WLE 13h44mins, W-WLE 13h56mins, p=0.36). The overall day surgery rates were comparable in the two groups (M-WLE 75.2%, W-WLE 75.1%, p=0.99). Conclusion: In the present series, M-WLE has been shown to be oncologically safe and non-inferior to W-WLE with a significantly lower re-excision rate. In addition to this, the reduced pre-operative waiting time on the day of surgery in the M-WLE group will have a positive effect on the patient journey. Further research should focus on the potential impact on day-bed utilisation and theatre efficiency. Table 1: Patient demographics and tumour characteristicsMagseed™Wirep valuen105133Median age (years)64 (34-87)60 (28-82)0.05Median BMI28.2 (17-54.4)28.3 (18.8-43.1)0.62PathologyInvasive+/-DCIS851100.31DCIS1715Others38Mean tumour diameter (mm)Invasive+/-DCIS15.19 (3-55)15.52 (1-15)0.82DCIS9.41 (3-45)17.12 (3-55)0.13 Table 2: Tumour to specimen ratio, further intra-operative cavity shaves and re-excision ratesMagseed™Wirep valuen102125Mean Tumour/Specimen RatioInvasive+/-DCIS8.8%18.1%0.20DCIS18.4%24.8%0.75Further intra-operative cavity shavesTotal48 (47.0%)68 (54.4%)0.27Invasive+/-DCIS28/64 (43.7%)56/102 (54.9%)0.16DCIS7/15 (46.6%)8/15 (53.3%)0.71Oncoplastic procedures: Invasive+/-DCIS12/21 (57.1%)4/7 (57.1%)1Oncoplastic procedures: DCIS1/2 (50%)0/1 (0%)NARe-excisions of marginsTotal3 (2.9%)13 (10.4%)0.03Invasive+/-DCIS3/64 (4.6%)8/102 (7.8%)0.4DCIS0/15 (0%)5/15 (33.3%)NAOncoplastic procedures: Invasive+/-DCIS0/21 (0%)0/7 (0%)NAOncoplastic procedures: DCIS0/2 (0%)0/1 (0%)NA Citation Format: Kirti Katherine Kabeer, Manoj S Gowda, Zatinahhayu MohdIsa, Megan Thomas, Vallipuram Gopalan, Sadaf Jafferbhoy, Soni Soumian, Sankaran Narayanan, Robert Kirby, Sekhar Marla. Oncological safety and patient journey with magseed™ localised breast conserving surgery [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS1-34.

Abstract PS1-15: Does breast cancer subtype impact margin status in patients undergoing partial mastectomy?

Abstract BACKGROUND: It is known that breast cancer subtype (e.g., luminal vs. triple negative (TN)) can affect response to systemic therapy and prognosis; however, it is less well-understood whether these subtypes affect margin status and should therefore alter surgical management. METHODS: Data from two randomized trials evaluating cavity shave margins (CSM) on margin status in patients undergoing partial mastectomy (PM) were used for this analysis. The data were restricted to patients who had invasive carcinoma present in the PM specimen, and in whom data for all three receptors (ER, PR and HER-2) were known. Patients were classified as luminal if they were ER and/or PR+, HER-2 enriched if they were ER and PR negative but HER-2 positive, and TN if they were negative for all three receptors. We evaluated the impact of subtype on the margin status at the time the surgeon had completed their standard PM, prior to randomization to CSM vs. no CSM. Non-parametric statistical analyses were performed using SPSS Version 26. RESULTS: 350 patients were included in this cohort for analysis. The median patient age was 64 (range; 32-94 years) and the median invasive tumor size was 1.2 cm (range; 0.6-8.0 cm). 326 (93.1%) were luminal type, 22 (6.3%) were triple negative, and 2 (0.6%) were HER-2 enriched. Subtype was significantly correlated with race (black patients were more likely to have TN disease than white patients, 22.2% vs. 3.8%, p=0.001), palpability (TN tumors were more likely to be palpable than luminal cancers 54.5% vs. 29.8%, p=0.007) and grade (78.9% of TN cancers were high grade vs. 13.5% of luminal cancers p&amp;lt;0.001). Subtype did not correlate with Hispanic ethnicity, node positivity, nor lymphovascular invasion (p&amp;gt;0.05 for all). While patients with TN and HER-2 enriched tumors were more likely to receive neoadjuvant therapy, this did not reach statistical significance (p=0.117). Surgeons were no more likely to take selective margins on the basis of molecular subtype (p=0.413). In this cohort, the overall positive margin rate was 33.7%. This did not vary based on molecular subtype (positive margin rate: 33.7% for patients with luminal tumors vs. 36.4% for those with TN tumors, p=0.425). On multivariate regression controlling for molecular subtype, race, grade and palpability, the only factor which predicted positive margin status was grade (p=0.005), with high grade tumors being significantly more likely to have a positive margin than low grade tumors, independent of other factors (OR=3.503, 95% CI: 1.638-7.494, p=0.001). CONCLUSION: While molecular subtype correlates with race, tumor grade and palpability, it does not predict margin status. Therefore, molecular subtype should not, independent of other factors, influence surgical decision-making. Citation Format: Andrew Fenton, Elisabeth Dupont, Theodore Tsangaris, Carlos Garcia-Cantu, Marissa Howard-McNatt, Akiko Chiba, Adam Berger, Edward Levine, Jennifer Gass, Kristalyn Gallagher, Sharon Lum, Ricardo Martinez, Alliric Willis, Sonali Pandya, Eric Brown, Amanda Mendiola, Mary Murray, Naveenraj Solomon, Maheswari Senthil, David Ollila, David Edmonson, Melissa Lazar, Jukes Namm, Fangyong Li, Meghan Butler, Noreen McGowan, Maria Herrera, Yoana Avitan, Brian Yoder, Laura Walters, Tara McPartland, Victor Haddad, Hongwei Ma, Ming Xie, Anees Chagpar. Does breast cancer subtype impact margin status in patients undergoing partial mastectomy? [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS1-15.

Intraoperative frozen section assessment of cavity shave margins in patients undergoing breast conservation surgery

Background: Surgical management of breast cancer has taken a paradigm shift from the early days of the radical Halstedian approach to a newer, relatively conservative approach. Breast conservation surgery (BCS) is the surgery of choice for early breast cancer (EBC). Pathological margin status is the single most important prognostic factor in patients undergoing BCS. Rates of margin positivity after BCS varies between 3- 20%. Multiple techniques have been applied to decrease margin positivity rates in BCS. We evaluated the impact of Intraoperative frozen section assessment of cavity shave margins (IFSA) in patients with EBC undergoing BCS

Impact of Cavity Shave Margins on Margin Status in Patients with Pure Ductal Carcinoma In Situ

We examined the impact of cavity shave margins (CSMs) on margin status in patients with pure ductal carcinoma in situ (DCIS) undergoing partial mastectomy (PM). One hundred and nine patients from 2 multicenter, randomized controlled trials were identified with pure DCIS (no invasive cancer). Surgeons performed their best PM, with specimen radiography and resection of selective margins per surgeon discretion. Patients were then randomized to have CSM resected or not. A positive margin was defined as <2 mm from ink. Median patient age was 63 years; median size of DCIS was 1.20 cm; 43.6% of patients had high-grade DCIS; and 58 (53.2%) patients were randomized to take CSM. The "shave" and "no-shave" groups were well-matched for age, race, ethnicity, palpability, grade, and size of DCIS. Although 33 (56.9%) of the patients in the shave group had a positive margin before randomization, only 12 (20.7%) had a positive margin after randomization to CSM (p<0.001). In the no-shave group, 17 patients (33.3%) had a positive margin. Controlling for size and grade of DCIS, taking CSM resulted in a nearly 65% reduction in the positive-margin rate (odds ratio 0.366; 95% CI, 0.136 to 0.981; p= 0.046). Size of DCIS remained an independent predictor of positive margins in the model (odds ratio 1.646; 95% CI, 1.227 to 2.209; p= 0.001). CSM reduces positive-margin rates in patients with pure DCIS, and can be a practical solution for DCIS patients who tend to have a high rate of margin positivity.

Impact of systematic cavity shave margins in breast-conserving surgery at a large community hospital with a low baseline re-excision rate.

Systematic cavity shave margins (CSM) can decrease rate of positive margins and re-excision beyond that of selective CSM. The objective of this study was to determine whether systematic CSM decreased re-excision rate in a population with a low baseline re-excision rate. We conducted a retrospective chart review of patients who underwent breast-conserving surgery (BCS) from November 2013 to November 2017. Primary end points were re-excision rate and margin status. Secondary end points were total volume of tissue excised, operative time, and concordance of core needle biopsy (CNB) pathology with final surgical pathology. The re-excision rates were 14.29% in the no shave margin group; 15.38% in the selective CSM; and 14.59% in the systematic CSM (P=.985). Odds of re-excision with ductal carcinoma in situ (DCIS) was 5.04 times greater than with invasive cancer (INV) and 1.94 times higher than with INV and DCIS. There was no significant difference in positive margins between groups (P=.362). Mean specimen volume was lowest in the systematic CSM group (64.6cm3 ), compared to no CSM and selective CSM (94.6cm3 and 91.8cm3 , respectively). With inclusion of shave margin volumes, total volume removed was not significantly different between no shave margin group (94.6cm3 ) and systematic CSM (89.7cm3 ) (P=.949). For patients with invasive ductal carcinoma (IDC) alone on their initial biopsy pathology, 69% were discovered to also have DCIS upon final pathology. Re-excision rate and specimen volume between all groups were not statistically different. There was a higher re-excision rate when DCIS was present, especially when not identified on CNB. As systematic CSM is most impactful when DCIS is involved, it is important to establish its presence for proper surgical planning.

Intraoperative ultrasonography-guided surgery: An effective modality for breast conservation after neo-adjuvant chemotherapy.

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.

Chest wall perforator flaps in partial breast reconstruction after breast conservation surgery: an additional oncoplastic surgical option

Partial breast reconstruction using chest wall perforator flaps (CWPF) is a recent option used by breast surgeons, mainly for lateral quadrant defects with a relatively large volume of excision. We report a single-centre experience of CWPF with surgery details, complications, re-excision, aesthetic and oncological outcomes.This was a prospective observational cohort study of patients who had undergone breast conservation surgery (BCS) plus CWPF reconstruction. All variables were recorded prospectively in the institutional database. A survey was done to analyse patient satisfaction at about 6 months after completion of radiotherapy.Forty patients had CWPF based reconstruction in 3 years. 57.5 % of patients had lateral intercostal artery perforator (LICAP) flap, 5% had lateral thoracic artery perforator (LTAP) flap, 27.5% had combined LICAP plus LTAP and 10% patients had anterior intercostal artery perforator (AICAP) flap. Tumour excision cavity defect was of the lateral quadrant in 82.5%, central quadrant in 10% and medial quadrant in 7.5% of patients. The margin was positive for five patients, out of which four required cavity shave and one had a mastectomy. One patient had complete flap loss, and two patients developed surgical site infection. 96% of patients were satisfied with the scar, and 88% were happy with the treated breast in comparison to the opposite breast. 92% were comfortable going out in public and felt that in retrospect their decision not to have a mastectomy was correct. With a median follow up of 18 (10, 22) months, one patient died, and four had recurrences.CWPF may be used for partial breast reconstruction in the small non-ptotic breast with excellent outcome and high patient satisfaction scores.

The technique and accuracy of breast specimen ultrasound in achieving clear margins in breast conserving surgery.

The aim of this prospective study was to determine whether breast specimen ultrasound (SUS) can reliably be used to confirm whether ultrasound (US) visible breast malignancies are excised with clear margins during breast-conserving surgery (BCS), in order to avoid a second operation and recurrence. A total of 95 consecutive participants with US visible malignancies, undergoing BCS, had the excised breast specimen transported to the radiology department intraoperatively. Breast SUS was used to confirm the presence of the lesion and measure the medial, lateral, superior and inferior margins. Margins<10mm prompted a call to theatre to recommend an immediate cavity shave. The accuracy of the SUS technique in confirming the lesion is contained within the specimen, and the correlation of radial margins on US and histology was assessed retrospectively. Breast SUS had 100% accuracy in confirming the presence of 99 lesions. 384 corresponding US and invasive carcinoma histological margins were compared. A 10mm or greater margin on US has a sensitivity of 56% (95% CI 21-86), specificity of 93% (95% CI 90-95) and accuracy of 92% (95% CI 89-95) in predicting no ink on tumour histologically, with a positive predictive value of 16% (95% CI 5-34) and negative predictive value of 99% (95% CI 97-99%). The area under the curve was 0.746 (95% CI 0.572-0.921). Breast SUS is a fast and reliable technique. Mammographically occult breast malignancies that are sonographically evident should undergo SUS to confirm the presence of the lesion and assess its macroscopic margins to avoid a re-excision.

The Impact of Neoadjuvant Chemotherapy on Margin Re-excision in Breast-Conserving Surgery.

Neoadjuvant chemotherapy (NAC) can improve cosmesis by reducing resection volume. Breast-conserving surgery (BCS) aims to achieve clear excision margins while optimizing cosmesis. However, the influence of NAC on margin re-excision after BCS is unclear. This study examines the rate and determinants of margin re-excision in patients undergoing BCS following NAC in our institution. From 2011-2015, all patients treated with NAC prior to BCS were identified from a prospectively maintained database. Mann-Whitney and Fisher's exact test tests were used to compare variables in patients who did and did not require re-excision. Patients undergoing primary surgical treatment in 2015 comprised an unmatched comparison group. Of 211 patients treated with NAC, 69 initially underwent BCS. The re-excision rate was 32% (n = 22) compared to 17% in the primary operable group (38 of 221, p = 0.02). Re-excision rates were lowest in triple-negative and HER2+ tumors (0% and 10%, respectively). Lobular carcinoma and ER+ tumors had a significantly higher rate of re-excision (100% and 42%, respectively). Of 22 patients undergoing re-excision, 9 had further BCS and 13 had a mastectomy. The re-excision rate following NAC is almost twice that of patients who underwent primary operative management. Her2+ and triple-negative tumors have lower re-excision rates and may represent a selected cohort most suitable for BCS. Patients with invasive lobular carcinoma or ER+ disease have significantly higher rates of margin positivity, and these patients should be considered for a cavity shave during primary surgery to reduce the rates of re-excision.

Resection of Cavity Shave Margins in Stage 0-III Breast Cancer Patients Undergoing Breast Conserving Surgery: A Prospective Multicenter Randomized Controlled Trial.

Single-center studies have demonstrated that resection of cavity shave margins (CSM) halves the rate of positive margins and re-excision in breast cancer patients undergoing partial mastectomy (PM). We sought to determine if these findings were externally generalizable across practice settings. In this multicenter randomized controlled trial occurring in 9 centers across the United States, stage 0-III breast cancer patients undergoing PM were randomly assigned to either have resection of CSM ("shave" group) or not ("no shave" group). Randomization occurred intraoperatively, after the surgeon had completed their standard PM. Primary outcome measures were positive margin and re-excision rates. Between July 28, 2016 and April 13, 2018, 400 patients were enrolled in this trial. Four patients (2 in each arm) did not meet inclusion criteria after randomization, leaving 396 patients for analysis: 196 in the "shave" group and 200 to the "no shave" group. Median patient age was 65 years (range; 29-94). Groups were well matched at baseline for demographic and clinicopathologic factors. Prior to randomization, positive margin rates were similar in the "shave" and "no shave" groups (76/196 (38.8%) vs. 72/200 (36.0%), respectively, P = 0.604). After randomization, those in the "shave" group were significantly less likely than those in the "no shave" group to have positive margins (19/196 (9.7%) vs. 72/200 (36.0%), P < 0.001), and to require re-excision or mastectomy for margin clearance (17/196 (8.7%) vs. 47/200 (23.5%), P < 0.001). Resection of CSM significantly reduces positive margin and re-excision rates in patients undergoing PM.