Intraoperative Specimen Radiography Research Articles

Abstract PO1-23-07: The effect of intra-operative margin assessment during breast conserving surgery for breast cancer in a Dutch cohort

Abstract Background Pre-operative tumour localisation and intraoperative specimen radiography are necessary to perform adequate resection of non-palpable breast tumours. Intraoperative digital specimen mammography (IDSM), is an alternative to conventional specimen radiography (CSR) and has the benefit of providing immediate specimen evaluation and the potential of decreasing operation time. IDSM may also reduce positive margins and re-excision rates. IDSM was implemented in our hospital in 2018. The study objective was to evaluate the surgery time, radicality and re-excisions in IDSM and CSR. Methods A single centre retrospective cohort study with two cohorts: CSR (n=532) and IDSM (n=475). The primary outcome was duration of surgery. Secondary outcomes were margin status of the primary surgery, the perioperative cavity shave rate and the re-excision rate. Differences between cohorts were compared using univariate statistics and multiple regression to adjust for variables that were statistically significantly associated with duration of surgery. Results IDSM use was associated with 8 minutes shorter surgery time (B -8.242, p < 0.001). Treatment variables independently associated with the duration of surgery were use of IDSM, type of (axillary) surgery and the performance of cavity shaving. Cavity shaves were more often performed when IDSM was used (24% versus 14% in CSR group, p < 0.001), while the proportion of radical first surgeries (93% versus 96% respectively, p = 0.070) was comparable. Conclusion IDSM was associated with a modest reduction in duration of surgery. Surgeons performed more cavity shaves since IDSM but this was not reflected by a lower proportion of patients with positive margins. Table 1. Baseline characteristics of the CSR versus the IDSM cohort Table 2. Results of surgery in the CSR versus the IDSM cohort. Citation Format: Sophie Wooldrik, Elles van de Voort, Taco Klem, Thijs van Dalen, Cornelis Verhoef, Gerson Struik, Erwin Birnie. The effect of intra-operative margin assessment during breast conserving surgery for breast cancer in a Dutch cohort [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO1-23-07.

Conventional specimen radiography in breast-conserving therapy: a useful tool for intraoperative margin assessment after neoadjuvant therapy?

PurposeA previous study in our breast unit showed that the diagnostic accuracy of intraoperative specimen radiography and its potential to reduce second surgeries in a cohort of patients treated with neoadjuvant chemotherapy were low, which questions the routine use of Conventional specimen radiography (CSR) in this patient group. This is a follow-up study in a larger cohort to further evaluate these findings.MethodsThis retrospective study included 376 cases receiving breast-conserving surgery (BCS) after neoadjuvant chemotherapy (NACT) of primary breast cancer. 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.Results362 patients with 2172 margins were assessed. The prevalence of positive margins was 102/2172 (4.7%). CSR had a sensitivity of 37.3%, a specificity of 85.6%, a positive predictive value (PPV) of 11.3%, and a negative predictive value (NPV) of 96.5%. The rate of secondary procedures was reduced from 75 to 37 with a number needed to treat (NNT) of CSR-guided intraoperative re-excisions of 10.In the subgroup of patients with clinical complete response (cCR), the prevalence of positive margins was 38/1002 (3.8%), PPV was 6.5% and the NNT was 34.ConclusionThis study confirms our previous finding that the rate of secondary surgeries cannot be significantly reduced by CSR-guided intraoperative re-excisions in cases with cCR after NACT. The routine use CSR after NACT is questionable, and alternative tools of intraoperative margin assessment should be evaluated.

Abstract P3-04-09: 3-dimensional intraoperative analysis of screen-detected breast cancers reduce re-excision rates

Abstract Introduction: Breast conserving therapy, has generally been accepted as treatment of choice for early invasive breast cancer. However adequate local control depends on obtaining negative margins and receipt of radiation In 20-30 % of patients with breast conserving surgery a second re-excision procedure is due to tumor-positive margins at histopathology. Margins re-excision rate are variable across the countries. Mean re-excision rate of 17.2% across units in UK. Intraoperative specimen radiography,used to evaluate partial mastectomy specimens ensure that the lesion is adequately removed. Objective: to determine whether 3D-intraoperative imaging better predicts margin status and reduces the re-excision rate than conventional 2D imaging. Methods: Retrospective study comparing two cohorts of patients 360 screen-detected breast cancer (2D cohort). April 2015 to March 2018 300 screen-detected breast cancer (3D cohort) April 2018 to March 2021 Royal Cornwall Hospital (RCHT) introduced a 3D intraoperative system for all cases in April 2018 Prior to the introduction of 3D intraoperative imaging at RCHT the re-excision rate was stable at approximately 15%. All patient had undergone preoperative digital mammogram and ultrasound. All patients had core biopsy diagnosis All malignancies were localised with ROLL (Radio-guided occult lesion localization) techniques. All wide local excision were performed by 5 fully trained oncoplastic breast surgeons (similar distribution within the two cohort) Specimen radiograph was performed intraoperatively using: 2D x-ray device (Faxitron system; Trident Hologic, Marlborough, MA) or 3D tomosynthesis (Mozart system; Kubtec Medical imaging, Stratford,CT). For both methods of assessment,specimen was placed in the device and auto exposed without any compression of tissue. All specimens were marked with orienting sutures and clips according to local protocol. All specimens were painted in theatre by the operating surgeon. All specimens were examined by the same pathologists. No change in margin protocol for 12 years(already compliant to ABS guidelines) • A clear margin for invasive cancer was defined as tumour found within 1mm of margin. For ductal carcinoma in situ (DCIS), a margin was classified as positive if ink on tumour, was classified as close ink is found in under 2 mm from tumour and as negative if more or equal to 2 mm, in accordance with NICE guidelines. (22) Statistical Analysis: • The study compares patient demographics, histology, and re-excision rates between 2D and 3D • Descriptive and comparative statistics are be calculated for all collected data TABLE 1: 3D/2D RR 0.59 (P:0.01), CI 0,3369-09068, Z -2.3473, P 0.0189 Conclusions: The use of intraoperative 3D specimen X-ray reduced the relative risk of re-excision rate by 41% (P=0.01) without any negative impact on other parameters. Table 1: Results 3D intraoperative imaging versus 2D intraoperative imaging Citation Format: Jo Mondani, Hamza Arabiyat, Stavroula Kastora, Mona Sulieman, Imran Abbas, Polly King, Rachel English, Iain Brown, Miklos Barta, Nicola Jackson, Philip Drew. 3-dimensional intraoperative analysis of screen-detected breast cancers reduce re-excision rates [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P3-04-09.

2022 Canadian Surgery Forum Sept. 15–17, 202201. Operative classification of ventral abdominal hernias: new and practical classification02. Watchful waiting for large primary splenic cysts03. Transversus abdominis plane (TAP) blocks with and without dexamethasone in colorectal surgery04. What factors determine publication of resident research day projects?05. Characterization of near-infrared imaging and indocyanine green use amongst general surgeons06. Variation in opioid prescribing

# 01. Operative classification of ventral abdominal hernias: new and practical classification {#article-title-2} Ventral hernias of the abdomen are defined as a noninguinal, nonhiatal defect in the fascia of the abdominal wall. Unfortunately, there is not currently a universal classification system

Radiopaque tissue transfer and X-ray system versus standard specimen radiography for intraoperative margin assessment in breast-conserving surgery: randomized clinical trial.

BackgroundReduction of positive margin rate (PMR) in breast-conserving surgery (BCS) of non-palpable breast cancer remains a challenge. The efficacy of intraoperative specimen radiography (SR) is unclear. This randomized trial evaluated whether the PMR was reduced by the use of devices that allow precise localization of the affected margins.MethodsPatients with microcalcification-associated breast cancer undergoing planned BCS were enrolled. Study participants were randomized to receive either SR with radiopaque tissue transfer and X-ray system (KliniTrayTM) or the institutional standard procedure (ISO). In all patients with a radiological margin less than 5 mm, an immediate re-excision was conducted. The primary outcome was the PMR. Risk factors for positive margins and the effect of immediate re-excision on final surgery were secondary analyses.ResultsAmong 122 randomized patients, 5 patients were excluded due to the extent of primary surgery and 117 were available for analysis. Final histopathology revealed a PMR of 31.7 per cent for the KliniTrayTM group and 26.3 per cent for the ISO group (P = 0.127). Independent factors for positive margins were histological tumour size more than 30 mm (adjusted OR (aOR) 10.73; 95 per cent c.i. 3.14 to 36.75; P < 0.001) and specimen size more than 50 mm (aOR 6.65; 95 per cent c.i. 2.00 to 22.08; P = 0.002). Immediate re-excision due to positive SR led to an absolute risk reduction in positive margins of 13.6 per cent (from 42.7 to 29.1 per cent).ConclusionSpecimen orientation with a radiopaque tissue transfer and X-ray system did not decrease the PMR in patients with microcalcification-associated breast cancer; however, SR and immediate re-excision proved to be helpful in the reduction of PMR.Registration numberDRKS00011527 (https://www.drks.de).

3-dimensional intraoperative analysis of screen detected breast malignancies reduces re-excision rates

Introduction: In the UK 20-30% of patients undergoing breast conserving surgery require a re-excision due to positive margins. Intraoperative specimen radiography is often used to guide the primary excision in screen detected lesions. The recent introduction of 3-dimensional tomographic analysis of the specimen has the potential for a more accurate intraoperative assessment of excision margins to guide the extent of primary excision.

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

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.

Is specimen radiography still necessary in patients with non-palpable breast cancer undergoing breast-conserving surgery using radioactive I-125 seed localization?

AimTo evaluate the diagnostic performance for margin assessment of specimen radiography (SR) in breast conserving surgery (BCS) using radioactive I125-seed localization (RSL). MethodsThe clinical, radiographic and histopathological data of women who underwent BCS after pre-operative RSL with intraoperative SR during nine consecutive years were analyzed. The histological margin and radiographic margin outcomes on SR were compared and results of intraoperative re-excisions were investigated. ResultsA consecutive series of 448 women with invasive carcinoma (n = 211), ductal carcinoma in situ (DCIS) (n = 79) and a combination of DCIS and invasive carcinoma (n = 158) were included. The median minimal margins for the radiological masses and microcalcifications measured on SR were 14 mm and 11 mm, respectively. Based on a radiological cut-off SR margin value of 1 mm, the overall sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were 21.0%, 95.0%, 26.0%, and 94.0%, respectively. The area under the receiver-operating curve was 0.73. Intraoperative re-excisions based on SR were performed in 31 (6.9%) patients; histopathological examination of the additional excised tissue revealed DCIS or invasive carcinoma in 6 (19.4%) patients. Hence, SR was beneficial for 6/448 patients (1.3%), and unnecessary intraoperative re-excisions were performed in 20/448 patients (4.5%). The number need to treat is 75; this implies that per 75-SR one resection with involved margins is prevented. ConclusionSR has a moderate diagnostic performance for margin involvement using RSL. A more accurate intraoperative margin assessment tool is warranted.

Advantages of intraoperative digital specimen radiography (IDSR) in breast surgery.

e12613 Background: Breast cancer is in first place among malignant diseases in women in Russia. We can provide, in most cases, breast-conserving surgery (BCS), due to progress in early diagnosis. Evaluation of positive margins is still one of the most important objectives in breast-conserving surgery. Objectives: To assess the benefits of IDSR in BCS of patients with “carcinoma in situ”. Methods: The results of treatment of 55 patients with breast cancer “carcinoma in situ” in our clinic were evaluated in two comparable groups. Group A included 28 patients, who were operated on from January 2019 to June 2019 and had breast-conserving surgery without IDSR. Group B included 27 patients, who were operated on from June 2019 to January 2020 and had breast-conserving surgery with the evaluation of margins by IDSR. Results: In a planned histological examination positive margins were detected in group A in 4 cases (14%) and required reoperation. In group B all margins were clear. After IDSR, 6 (22%) patients out of 27 in this group showed microcalcifications in the resection margins or at a distance of less than 1 mm and required intraoperative additional excision to obtain clean margins. Conclusions: IDSR reduces the frequency of reoperation due to increased detection of positive margins, allows to correct scope and duration of surgery because of impact on the time of the surgical decision-making process.

Abstract P1-01-05: Intraoperative three-dimensions MiniiSCANR for determine adequate margin in breast cancer specimens before histopathological examination

Abstract Background: 20-30% of breast conserving surgery patients undergo a second re-excision procedure due to tumor-positive margins at final histopathology. Various modalities are used to assess the adequacy of surgical resection to minimize positive margin and reoperation rates. MiniiSCAN™ is a method of intraoperative specimen radiography that allows for margin evaluation following excisional breast lesion either BI-RADS 4 and 5. The mechanism of MiniiSCAN™ is similar to computer tomography but specimen is rotated on the plate instead circular rotating frame with an x-ray tube mounted on 1 side and a detector on the opposite side in conventional computerized tomography scan. It is easily and short time to reconstructed into 3 dimensions. This machine was developed by Songklanagarind hospital and National Science and Technology Development Agency, Thailand. Objective: To evaluate the efficacy of MiniiSCAN™ as a surgical margin guidance tool compared with pathological margin in breast cancer specimens. Materials &amp; Methods: A retrospective review was designed, 62 consecutive cases of abnormal mammogram (BI-RADS 4,5) with or without wire localization from 1 June 2016 to 30 June 2019 were identified from the electronic medical records at Prince of Songkla University. Results: Of the 62 specimens imaged, 17 had invasive cancer and ten had in-situ pathological diagnoses. Of these, 10 patients had a positive tumor margin and 17 a negative tumor margin at final histopathology. Margin status evaluation by MiniiSCAN™ reconstruction were calculated in 4 minutes (acquisition and reconstruction time). Of the 27 specimens readings, the margin status in 24 patients was correctly predicted by MiniiSCAN™. There were two false-negative predictions. The accuracy, sensitivity, specificity, positive predictive value and negative predictive value of MiniiSCAN™ in margin status prediction were 88.89%, 80%, 94.11%, 88.89% and 88.89%, respectively. Conclusion: MiniiSCAN™ could be integrated into routine care, enabling the surgical team to perform and interpret specimen radiographs rapidly and make immediate surgical decisions. Keywords: Abnormal mammography, Breast cancer, CT scan, Specimen radiography Citation Format: Suphawat Laohawiriyakamol, Piyanun Wangkulankul, Piyanoot Woodtichartpreecha, Puttisak Puttawibul. Intraoperative three-dimensions MiniiSCANR for determine adequate margin in breast cancer specimens before histopathological examination [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-01-05.

Can micro-computed tomography imaging improve interpretation of macroscopic margin assessment of specimen radiography in excised breast specimens?

Peri-operative macroscopic margin assessment with standard intraoperative specimen radiography (IOSR) results in improved re-excision rates in excised breast tissue specimens but is limited. This study sought to improve the intraoperative margin assessment on standard IOSR techniques by utilizing noninvasive X-ray micro-computed tomography (micro-CT) imaging of breast tissue specimens to compare margins in three-dimensional with two-dimensional IOSR.Patients with impalpable breast carcinoma, or suspected breast carcinoma, who were eligible for breast-conserving surgery were recruited. Margins were assessed within each specimen using standard IOSR, micro-CT, and histology techniques.Six malignant and three benign lesions were included for the analysis in this study. Micro-CT identified the same positive margin as IOSR in 3 out of 6 malignancies. However, margin status identified by micro-CT was concordant with pathological assessment in only one specimen. In comparison, margin assessment by IOSR correctly correlated with pathological margin status in three malignant specimens.The use of micro-CT imaging in this study did not improve margin assessment in impalpable breast specimens when compared to standard specimen radiography (SR) assessment. However, future improvements in sample preparation and CT image acquisition processes may enhance the potential of micro-CT as a valuable imaging tool for improving margin assessment.

Step by step: Planning a needle localization procedure

In patients with nonpalpable early-stage breast cancer eligible for breast conservation surgery (BCS), wire-guided localization (WGL) is widely accepted as a standard technique for preoperative image-guided lesion localization. In preparation for this procedure, lesion location, size, type and configuration play important roles in preoperative localization planning. Successful preoperative planning requires review of all pertinent imaging studies, imaging reports and pathology reports, with special attention to pre- and post-biopsy imaging and evaluation of the targeted lesions and the type and the position of the marker clips. Preoperative communication with the surgeon is key in the planning process to ensure that clarity in localization objectives are reached in complex cases. This pictorial essay will provide a methodical, step by step approach to planning successful image-guided preoperative needle localizations. These steps include selection of the imaging modality, the equipment, the procedure and intraoperative specimen radiography. The case-based review will also include key steps and considerations during the planning stage, the procedure stage, and the post-procedure stage. These same techniques can also be applied to newer, non-wire image-guided breast localization techniques now available for widespread commercial use.

Efficacy of intraoperative specimen radiography as margin assessment tool in breast conserving surgery.

To explore the ability of intraoperative specimen radiography (SR) to correctly identify positive margins in patients receiving breast conserving surgery (BCS). To assess whether the reoperation rate can be reduced by using this method. This retrospective study included 470 consecutive cases receiving BCS due to a primarily diagnosed breast cancer. SR was carried out in two planes, assessing the specimen regarding the presence of the lesion and its relation to all margins. If indicated, re-excision of selective orientations was advised. Under consideration of gross inspection and the SR-findings, it was up to the surgeon whether to perform re-resections. The recommendations for re-excision were, separately for each orientation, compared to the histopathological results, serving as gold standard. Intraoperative SR was performed in 470 cases, thus 2820 margins were assessed. Of those, 2510 (89.0%) were negative and 310 (11.0%) positive. SR identified 2179 (77.3%) margins correctly as negative, whereas 331 (11.7%) clear margins were misjudged as positive. Of 310 infiltrated margins, SR identified 114 (4.0%) correctly, whereas 196 (7.0%) infiltrated margins were missed. This resulted in a sensitivity/specificity of 36.8%/86.8% and PPV/NPV of 25.6%/91.8%. Through targeted re-resections positive margins could be reduced by 31.0% [310 to 214 (7.6%)]. On case level, the rate of secondary procedures could be reduced by 37.0% [from 162 to 102 (21.7%)]. SR is a helpful tool to identify infiltrated margins and to reduce the rate of secondary surgeries by recommending targeted re-excisions of according orientations in order to obtain a final negative margin status.

Margins in Breast Conservative Surgery: Use of Intraoperative Specimen Radiography

Margins in Breast Conservative Surgery: Use of Intraoperative Specimen Radiography

Open Surgical Biopsy in Diagnosis of Mammographically Detected Suspicious Microcalcifications

Background: One of the earliest signs of breast cancer may be the presence of mammographically detected suspicious microcalcifications in the breast. The aim of the study was to present an open surgical biopsy of the mammographically detected suspicious microcalcifications in a breast, with preoperative wire marking of the lesions and intraoperative specimen radiography, as a reliable and valid procedure.Material and Methods: The study included 80 female patients underwent surgery because of mammographically detected suspicious microcalcifications. The method of preoperative ultrasound-guided wire marking of a zone of microcalcification was performed in all patients.After wire marking, the control native mammography in ML and CC projections was performed, in order to locate the microcalcifications relative to the wire. In all patients, the extirpation of the suspicious microcalcifications was verified by the specimen radiography.Results: In the definitive histopathological finding in situ component of ductal carcinoma of the breast was verified in nine (11,25%) examinees. High grade in situ component was verified in eight (10%) examinees and low grade in situ component in one examinee (1,25%). In 11 (13,75%) examinees, the invasive breast cancer with an extensive in situ component up to 50% was verified. In 46 (57,5%) of the examinees, benign, non-proliferative changes were verified, while proliferative changes characterized as premalignant condition (sclerosing adenosis, radial scar and atypical ductal hyperplasia) were verified in 14 (17,5%) examinees. Microcalcifications verified by specimen radiography are completely removed.Conclusion: Presence of mammographically detected suspicious microcalcifications has a significant predictive value in the early detection of breast cancer. The method of an open surgical biopsy, as an alternative to stereotactic biopsy, is valid in diagnostic of the mammographically suspicious microcalcifications.

Breast conserving surgery and intra-operative specimen radiography: Margin assessment by the surgeon or the radiologist?

In the United Kingdom since the late 1990s there has been both a shortage of and falling level in recruitment of breast radiologists/radiographers.

Breast conserving surgery and intra-operative specimen radiography: Margin assessment by the surgeon or the radiologist?

Breast conserving surgery and intra-operative specimen radiography: Margin assessment by the surgeon or the radiologist?

Performance characteristics of specimen radiography for margin assessment for ductal carcinoma in situ: a systematic review.

Reducing positive margin rate (PMR) and reoperation rate in breast-conserving operations remains a challenge, mainly regarding ductal carcinoma in situ (DCIS). Intra-operative margin assessment tools have emerged to reduce PMR over the last decades, including specimen radiography (SR). No consensus has been reached on the reliability and efficacy of SR in DCIS. We performed a systematic literature review to assess the performance characteristics of SR for margin assessment of breast lesions with pure DCIS and invasive cancers with DCIS components. A literature search was conducted for diagnostic studies up to April 2017 concerning SR for intra-operative margin assessment of breast lesions with pure DCIS or with DCIS components. Studies reporting sensitivity and specificity calculated using final pathology report as reference test were included. Due to improved imaging technology, studies published more than 15years ago were excluded. Methodological quality was assessed using quality assessment of diagnostic accuracy studies-2 checklist. Due to clinical and methodological diversity, meta-analysis was considered not useful. Of 235 citations identified, 9 met predefined inclusion criteria and documented diagnostic efficacy data. Sensitivity ranged from 22 to 77% and specificity ranged from 51 to 100%. Positive predictive value and negative predictive value ranged from 53 to 100% and 32 to 95%, respectively. High or unclear risk of bias was found in reference standard in 5 of 9 studies. High concerns regarding applicability of index test were found in 6 of 9 studies. The present results do not support the routine use of intra-operative specimen radiography to reduce the rate of positive margins in patients undergoing breast-conserving surgery for pure DCIS or the DCIS component in invasive cancer. Future studies need to differentiate between initial and final specimen margin involvement. This could provide surgeons with a number needed to treat for a more applicable outcome.

Intraoperative digital specimen radiography in the treatment of nonpalpable breast lesions

Introduction/Objective. About a third of the breast lesions on mammography are clinically occult. The goals of surgical treatment are to locate, remove, and verify their presence in the removed breast tissue. Standard specimen mammography (SSM) has been an official procedure for the latter, while intraoperative digital specimen radiography (IDSR) was introduced recently. The aim of this study was to evaluate the use of IDSR versus SSM and possible benefits regarding the duration of the procedures (operating room occupancy), availability of digital mammography for additional number of patients, surgeon productivity, and the quality of performed services. Methods. A retrospective chart review of 109 patients who underwent IDSR for nonpalpable breast lesions was performed between January 2014 and June 2016. We compared the difference in the duration of IDSR versus SSM procedure. We also observed the number of re-excisions and evaluated time-saving in the operating room workflow. Results. The average duration of surgery in the IDSR group of patients was 51 minutes, compared to 64 minutes in the SSM group. Every IDSR procedure saved 13 minutes over the standard SSM. That would allow another 28 procedures in the same time frame, with the same quality of service compared with SSM. In that way we increased productivity by 27.5%. Additional operation/surgery was needed for histologically involved surgical margins in three cases (2.75%). Conclusion. The use of new technology resulted in the rationalization of the operative room workflow and gave better productivity. More savings were obtained through the increase of digital mammography capacity for diagnostics, decrease of anesthesia duration, and better management of human resources. The number of ?true? re-excisions, involving additional surgery, remained similar after introducing IDSR.

The role of specimen radiography in breast-conserving therapy of ductal carcinoma in situ

BackgroundTo assess the role of intraoperative specimen radiography (SR) and to define risk factors for positive margins in breast-conserving therapy (BCT) of ductal carcinoma in situ (DCIS). MethodsIn a retrospective study in calcification-associated DCIS treated with BCT between January 2009 and December 2011, digital mammographs and SR were reviewed and radiological margin width was determined. Clinical, radiological, and histological data were correlated with surgical histological data, and a histologically free margin of at least 2 mm was taken as evidence of successful BCT. Results47/91 patients (51.6%) fulfilling the inclusion criteria had histologically involved surgical margins. Univariate analyses revealed DCIS size, mammographic extension of calcification, presence of comedo necrosis, negative progesterone receptor status, and a small radiological margin on SR to be risk factors for unsuccessful BCT. Receiver Operating Characteristic (ROC) analysis showed a radiological margin width of 4 mm to be optimal, with a sensitivity of 72.3% and specificity of 52.3%. The likelihood of surgical free margins was increased 2.9-fold with a radiological margin width ≥4 mm. On multivariate logistic regression analysis, only histological DCIS size >20 mm clearly emerged as an independent predictive factor for surgically involved margins (p < 0.001), while an SR margin <4 mm trended toward significance (p = 0.066). ConclusionsSR is a reliable method for predicting free surgical margins in non-invasive breast cancer where a minimum radiological free margin of 4 Fmm is achieved. However, histological DCIS size remains the most important factor determining successful BCT.