Lower Re-excision Rates Research Articles

Comparison of Wire and Non-Wire Localisation Techniques in Breast Cancer Surgery: A Review of the Literature with Pooled Analysis.

Background and Objectives: Wide local excision is a common procedure in the treatment of breast cancer. Wire-guided localisation (WGL) has been the gold standard for many years; however, several issues have been identified with this technique, and therefore, wire-free techniques have been developed. This scoping review synthesises the available literature comparing wire-guided localisation with the wire-free techniques used in breast-conserving cancer surgery. Materials and Methods: Multiple databases including Pubmed and MEDLINE were used to search articles between 1 January 2000 and 31 December 2022. Terms included "breast neoplasms", "margins of excision", and "reoperation". In total, 34/256 papers were selected for review. Comparisons were made between positive margins and re-excision rates of WGL with wire-free techniques including SAVI SCOUT, Magseed, ROLL, and RSL. Pooled p-values were calculated using chi-square testing to determine statistical significance. Results: Pooled analysis demonstrated statistically significant reductions in positive margins and re-excision rates when SAVI SCOUT, RSL, and ROLL were compared with WGL. When SAVI SCOUT was compared to WGL, there were fewer re-excisions {(8.6% vs. 18.8%; p = 0.0001) and positive margins (10.6% vs. 15.0%; p = 0.0105)}, respectively. This was also the case in the ROLL and RSL groups. When compared to WGL; lower re-excision rates and positive margins were noted {(12.6% vs. 20.8%; p = 0.0007), (17.0% vs. 22.9%; p = 0.0268)} for ROLL and for RSL, respectively {(6.8% vs. 14.9%),(12.36% vs. 21.4%) (p = 0.0001)}. Magseed localisation demonstrated lower rates of re-excision than WGL (13.44% vs. 15.42%; p = 0.0534), but the results were not statistically significant. Conclusions: SAVI SCOUT, Magseed, ROLL, and RSL techniques were reviewed. Pooled analysis indicates wire-free techniques, specifically SAVI SCOUT, ROLL, and RSL, provide statistically significant reductions in re-excision rates and positive margin rates compared to WGL. However, additional studies and systematic analysis are required to ascertain superiority between techniques.

Localisation accuracy with iodine-125 seed versus wire guidance for breast cancer surgery.

Impalpable breast lesions generally require image-guided localisation for breast-conserving surgery. A standard technique is to place a hook wire (HW) within the lesion. Radioguided occult lesion localisation using iodine seeds (ROLLIS) involves inserting a 4.5 mm iodine-125 seed (seed) into the lesion. We hypothesised that a seed could be more precisely positioned in relation to the lesion than a HW and that this may be associated with a lower re-excision rate. Retrospective review of consecutive participant data from three ROLLIS RCT (ACTRN12613000655741) sites. Participants underwent preoperative lesion localisation (PLL) with seed or HW between September 2013 and December 2017. Lesion and procedural characteristics were recorded. Distances between (1) any part of the seed or thickened segment of the HW ('TSHW') and the lesion/clip ('distance to device' DTD) and (2) centre of the TSHW/seed and centre of the lesion/clip (device centre to target centre 'DCTC') were measured on immediate postinsertion mammograms. Pathological margin involvement and re-excision rates were compared. A total of 390 lesions (190 ROLLIS and 200 HWL) were analysed. Lesion characteristics and guidance modality used were similar between groups. Ultrasound-guided DTD and DCTC for seed were smaller than for HW (77.1% and 60.6%, respectively, P-value < 0.001). Stereotactic-guided DCTC for seedswas 41.6% smaller than for HW (P-value = 0.001). No statistically significant difference in the re-excision rates was found. Iodine-125 seeds can be more precisely positioned for preoperative lesion localisation than HW, however, no statistically significant difference in re-excision rates was detected.

Preoperative MRI and Its Impact on Surgical Outcomes in Patients with Triple Negative Breast Cancer Treated with Primary Surgery: Did New Margin Guidelines or Cavity Shave Margins Practice Diminish the Role of Preoperative MRI?

Results of an earlier retrospective study from our institution suggested that patients with triple negative breast cancer (TNBC) who had preoperative MRI may have had an improved local recurrence rate (LRR) after breast conserving surgery (BCS). We aimed to clarify the impact of preoperative MRI on surgical outcomes in an expanded TNBC cohort treated by BCS in a contemporary era. Our study cohort comprised 648 patients with TNBC who underwent BCS between 2009 and 2018. Demographic and clinical characteristics were compared between those with (n=292, 45.1%) and without (n=356, 54.9%) preoperative MRI. Multivariable logistic regression was performed to assess the association of preoperative MRI with surgical outcomes. The crude LRR of 3.5% was lower than previously reported. Univariable analyses demonstrated that the LRR and re-excision rates in the MRI and no-MRI groups were 3.4 and 3.7%, 21.6% and 27.2%, p=0.876 and p=0.10, respectively. Multivariable logistic regression analyses demonstrated that preoperative MRI was not associated with a lower LRR: odds ratio (OR)=1.42 (p=0.5). During our study period, new margin guidelines and shave margins practice were adopted in 2014 and 2015. To account for their effects, the year of diagnosis/surgery and other clinical variables were adjusted in multivariable logistic regression and inverse probability weighting models to demonstrate that preoperative MRI remained associated with a lower re-excision risk, OR 0.56, p=0.04l; and a lower re-excision rate, 23.15% versus 36.0%, p<0.01, respectively. Our findings suggested that patients with TNBC anticipating BCS may benefit from preoperative MRI.

Comparison of excised breast volume, re-excision rate and margin positivity in breast-conserving surgery in breast cancer patients using and not using neoadjuvant chemotherapy

Background/Aim: One of the purposes of using neoadjuvant chemotherapy (NAC) is to evaluate the patients according to tumor-to-gland ratio, save them from mastectomy by reducing tumor dimension, and get more beautiful results cosmetically with less volume excision during breast-conserving surgery (BCS). Is it possible to achieve the goal of less volume excision after NAC? We aimed to compare the excised volume with BCS, margin positiveness and re-excision rates between the patients who received NAC and the ones who didn’t receive NAC in patients with breast cancer and to calculate the increase in BCS performability with NAC. Methods: Among 306 patients diagnosed with breast cancer between 2013 and 2021 at Gaziosmanpasa Training and Research Hospital, 105 patients who underwent BCS were included in this retrospective cohort study. Excised breast volume, surgical margin positiveness, re-excision and mastectomy rates were retrospectively compared in breast cancer patients underwent BCS with and without NAC. The patients who received BCS following NAC were named the primary chemotherapy (PC), and the patients whose treatment was initiated with BCS were named the primary surgery (PS) groups. Results: BCS was performed to 105 breast cancer patients, of which 28 (26.7%) received NAC, and 77(73.7%) started the treatment with surgery. There were no significant differences between the PC and PS groups with respect to excision volume (755.86 (725.69) and 709 (637.36), P=0.822). Re-excision was more common in PS than in the PC group (39.0% vs 10.7%, P=0.008). Fourteen patients who were candidates for mastectomy at the beginning, became eligible for BCS by receiving NAC, which caused a 15.38% increase in BCS applicability. Surgical margin positivity was seen in only 3 patients, which is why a statistical comparison wasn’t made. Conclusions: Although the tumor size was higher in the PC group, the excised breast volume did not show a significant difference between the two groups. PC decreased the re-excision rates in the chemotherapy candidate group. This data shows that patients who are candidates for adjuvant chemotherapy might be considered for PC to increase BCS success with lower re-excision rates and equivalent excised breast volume.

A Comparative Study between Round Block Technique and Standard Wide Local Excision in Breast Cancer Patients

Abstract Background The goal of optimizing the cosmetic and oncologic outcomes of BCS has been addressed in recent years by the emergence of the field of oncoplastic surgery, that originally defined as an assortment of volume replacement techniques performed by plastic surgeons to replace all or part of the resected breast volume with myocutaneous tissue flaps. The definition of oncoplastic surgery has more recently been expanded to include a wide range of volume displacement or volume redistribution procedures performed by breast surgeons and general surgeons to optimize breast shape and breast volume following breast cancer surgery. Aim of the Work To assess the round block technique as regard oncological safety, surgical outcomes and patients' satisfaction comparing results with standard wide local excision. Patients and Methods This is a prospective randomized study to assess the round block technique as an oncological procedure for management of early breast cancer near to nipple-areola complex as regard oncological safety, surgical outcomes and patients' satisfaction comparing results with standard wide local excision. Twenty breast cancer patients are subdivided into group (A) 10 females which underwent round block technique and group (B) 10 femaleswhich underwent standard wide local excision. Patient and tumor criteria including age, co morbidities, tumor size and distance between tumor and nipple-areola complex were considered to be non-significant between 2 groups so the only difference is the surgical technique. Results The round block technique and SWLE have the same results regarding operative time, intra-operative blood loss and post operative complications with the advantage to RBT because of its better cosmetic outcomes and lower re-excision rates. So, the round block technique is superior to SWLE in selected cases. Conclusion The round block technique has comparable operative parameters to SWLE with no evidence of increased surgical complications. With a lower re-excision rates and better cosmoses were observed in the round block patients as it is scarless operation without nipple and areola shift suggesting that the round block technique is superior to SWLE in selected cases.

Cosmetic outcomes following wide local excision of impalpable breast cancer: is radioguided occult lesion localization using iodine-125 seeds better than hookwire localization?

Hookwire localization (HWL) is the gold standard for localizing impalpable tumours for breast conserving surgery. An alternative technique, radioguided occult lesion localization using iodine-125 seeds (ROLLIS), has been associated with lower re-excision rates. This paper investigates if cosmetic outcomes differ in women undergoing breast conserving surgery with HWL or ROLLIS. Women who had ROLLIS or HWL guided excision for impalpable breast cancer within a multicentre randomized controlled trial (RCT) (ANZCTR 12613000655741) were recruited. Exclusions were level 2 oncoplasty and mastectomy. Cosmetic outcome was calculated using BCCT.core, the Hopwood Body Image Scale and estimated percentage breast volume excised. Chi-squared analysis was used to determine the difference between the intervention groups. Analysis was performed for 123 participants (66 ROLLIS and 57 HWL). The cosmetic outcome determined by BCCT.core for all participants was good with no significant difference between the ROLLIS and HWL groups. When reviewing the number of patients who experienced either a good or excellent result, there was a significantly higher number of patients in the ROLLIS group (n=53, 82%) compared to the HWL group (n=42, 74%, P=0.02. There were no differences in Hopwood Body Image Scale or estimated percentage breast volume excised between groups. There was a reduction in the frequency of re-excision in the ROLLIS group (n=3, 4.5%) versus HWL group (n=8, 14%); however, this was not significant (P=0.06). Pre-operative localization of impalpable breast lesions using either ROLLIS or HWL resulted in a good cosmetic outcome with no significant difference between localization techniques.

Intraoperative ultrasound is associated with low re-excision rates following breast conserving surgery for non-palpable invasive breast cancers

BackgroundWire localized breast biopsy (WLB) is the most commonly performed procedure for the removal of non-palpable breast cancer. It is associated with patient discomfort and high re-excision rates. Intraoperative ultrasound (IOUS) is an alternative technique that may improve patient experience and have lower re-excision rates. MethodsA retrospective, single surgeon experience with IOUS is compared with WLB. Case matching for variables known to impact re-excision rates is performed. Fisher’s exact test was performed for categorical variables, and a T-test for continuous variables. Results28 patients underwent IOUS and WLB. Re-excision rates were the same in patients undergoing IOUS and WLB (10.7% vs 0%; p = 0.24). The calculated resection ratio was lower with IOUS than WLB (2.99 vs 3.46; p = 0.37), but did not reach statistical significance. ConclusionIn selected patients, intra-operative ultrasound can be performed with a favourable re-excision rate, and comparable amounts of tissue compared to wire localized breast biopsy.

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.

Hospital System Adoption of Magnetic Seeds for Wireless Breast and Lymph Node Localization.

As an alternative to traditional wire localization, an inducible magnetic seed system can be used to identify and remove nonpalpable breast lesions and axillary lymph nodes intraoperatively. We report the largest single-institution experience of magnetic seed placement for operative localization to date, including feasibility and short-term outcomes. Patients who underwent placement of a magnetic seed in the breast or lymph node were identified from July 2017 to March 2019. Imaging findings, core needle biopsy, surgical pathology results, and type of surgery were collected. Outcomes included procedural complications, magnetic seed and biopsy clip retrieval rates, and need for additional surgery. A total of 842 magnetic seeds were placed by nine radiologists in 673 patients and retrieved by six surgeons at six operative locations. The majority of breast lesions were malignant (395/659, 59.9%); 136 seeds were placed for lymph node localization. The overall magnetic seed retrieval rate was 98.6%, whereas the biopsy clip retrieval rate was 90.9%. Only six patients (0.7%) experienced a complication from magnetic seed placement. Reexcision was performed in 15.2% of patients with breast cancer; 9.6% of benign/high risk lesions were upgraded to malignancy at surgical excision. The magnetic seed technique is safe, effective, and accurate for localization of breast lesions and lymph nodes, and importantly uncouples surgery from the localization procedure. The high magnetic seed retrieval rate and low reexcision rate may reflect the accuracy of magnetic marker placement as a "second chance" localization procedure, especially in cases with biopsy clip migration.

A comparative study between round block technique and standard wide local excision in patients with breast cancer

Background The purpose of optimizing the cosmetic and oncological results of breast conservative surgery (BCS) has been addressed in recent years by the advent of the field of oncoplastic surgery, originally defined as an assortment of volume replacement techniques. Recently, the concept of oncoplastic surgery has been expanded to include a wide range of volume-displacement or volume-transfer procedures performed by breast surgeons and general surgeons to improve breast shape and breast volume during breast cancer operations. Aim The aim was to assess the round block technique regarding oncological safety, surgical outcomes, and patients’ satisfaction and to compare the results with standard wide local excision. Patients and methods This is a prospective randomized trial to test the round block technique as an oncological procedure for the early management of breast cancer near the nipple–areola complex in terms of oncological safety, surgical outcomes, and patients’ satisfaction and to compare the results with standard wide local excision. A total of 20 patients with breast cancer were subdivided into group A, which comprised 10 female patients who underwent round block technique, and group B, which comprised 10 female patients who underwent standard wide local excision. Patient and tumor criteria, including age, comorbidities, tumor size, and distance between tumor and nipple-areola complex, were considered to be nonsignificant between the two groups, so the only difference is the surgical technique. Results The round block technique and standard wide local excision (SWLE) have the same results regarding operating time, intraoperative blood loss, and postoperative complications, with radiation of breast therapy (RBT) being advantageous because of its better cosmetic outcomes and lower re-excision rates. Conclusion Despite no evidence of increased surgical complications, the round block procedure has equivalent operating parameters to SWLE. In round block, patients were found with lower re-excision rates and better cosmoses, as a scarless procedure, without nipple and areola shift, which indicates that the round block technique is superior to selected SWLE.

Differences in Re-excision Rates for Breast-Conserving Surgery Using Intraoperative 2D Versus 3D Tomosynthesis Specimen Radiograph

Intraoperative specimen radiographs performed during breast conservation surgery for cancer reduces the need for re-excision for positive margins. We studied 2D versus 3D image-guided cavity margin excision and compared it to final pathology and need for additional surgery. We conducted a retrospective review of 657 breast-conserving operations performed for cancer from 2013 to 2018. Procedures were performed by four surgeons at a single tertiary institution with access intraoperatively to 2D and 3D radiographs. Data collected included demographics, intraoperative margin assessment, final pathology, and re-excision rates. A total of 466 patients had 2D and 191 had 3D specimen imaging. The 2D group had a lower mean age and a higher body mass index and proportion of minority patients than the 3D group (P < 0.01). In the 3D group, there was a higher percentage of patients with mammographically denser breasts (P < 0.06); 58% of patients in the 3D group had additional imaging-directed cavity margins excised versus 32% of patients in the 2D group (P < 0.01). In the 2D group, 44 patients (9%) had positive final margins versus 8 patients (4%) in the 3D group (P = 0.02). No difference was found on total volume of excision (P = 0.56). The re-excision rate for the 2D group was 11% versus 5% for the 3D group (P = 0.02; adjusted odds ratio = 0.41, 95% confidence interval 0.19-0.86). Re-excision rates using both modalities are low. A lower re-excision rate is independently associated with 3D tomosynthesis. This allows surgeons to excise additional margins at the index operation, decreasing reoperations and anxiety/costs for patients.

Abstract P1-20-21: The use of intraoperative ultrasound and guidewire placement to obtain low re-excision rates and increased accuracy of excision in impalpable breast lesions at the Cambridge Breast Unit

Abstract INTRODUCTION: Increasingly we are dealing with more and more impalpable breast lesions thanks to screening programmes, chemotherapy and in situ disease. There are various techniques already employed for assisting in surgery for impalpable lesions such as radioactive and magnetic markers. All of these have limitations and are only useful in surgery. Ultrasound can be used in clinic and theatre to locate tumours and sonographically visible markers. In our experience in the Cambridge breast unit we have found it is more satisfactory to use guidewires that are intraoperatively or preoperatively placed using ultrasound guidance. This allows for direct approach to the lesion at the same time limiting the dissection and volume of resection. The guidewire allows tactile feedback and helps with precision and accuracy of the excision as reflected in the specimen weights. In this study we look at the outcomes of intraoperatively and preoperatively placed guidewires using ultrasound for impalpable breast lesions between 2015 -2018 in the Cambridge Breast Unit. The primary outcomes are re-excision rate and average specimen weights. METHODS: Patients undergoing breast conservation surgery for impalpable lesions from 01/01/2015 to 30/07/2018 were included. Data was collected retrospectively from our electronic records system EPIC and analysed. RESULTS The results were divided into intraoperative localisations and preoperative localisations. A total of 441 lesions in 415 patients were included in this study. Preoperative localisationIntraoperative localisationNumber of patients193222Number of lesions210231*Re-excision rate per patient %19.2%14.0%Specimen weight per patient (grams)39.4g24.2g*Fishers exact 0.24 (NS) CONCLUSION: Impalpable lesions can be successfully localised using ultrasound guidance and a guidewire both intraoperatively and preoperatively with good outcomes. Intraoperative localisation has lower re-excision rates and specimen weights in our study as well as many other benefits for the patient and surgeon. We have looked into how easily and quickly we can train ultrasound naïve trainees in this technique and have achieved good results. Citation Format: Primeera Wignarajah, Vasiliki Papalouka, Parto Forouhi. The use of intraoperative ultrasound and guidewire placement to obtain low re-excision rates and increased accuracy of excision in impalpable breast lesions at the Cambridge Breast Unit [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 P1-20-21.

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.

Re-excision rate after sector resection for breast cancer: A 5-year retrospective cohort study.

Positive margins after Breast conserving surgery (BCS) for breast cancer can result in local recurrence (LR) requiring further surgery. This can lead to unnecessary patient anxiety, poor prognosis and impose additional economic burden to our health system. The aim of this study is to assess the rate of re-excision for positive margins after BCS using the sector resection technique. This single centre retrospective cohort study included all women who underwent BCS using sector resection between the years of 2012 and 2016. A total of 456 patients underwent sector resection. We evaluated the margin status, re-excision rates and their predictive risk factors. 415 (91%) patients had clear margins. 41 (9%) patients underwent further re-excision for positive or close margin. 75.6% of those patients had DCIS and 51% had invasive carcinoma involving the margins. Patient and tumour characteristics associated with an increased risk of positive margin were women under the age of 50 (p = 0.19), tumours >50 mm (p = 0.001), grade-2 (p = 0.48) and grade-3 (p = 0.63), HER-2 positivity (p = 0.02), sentinel lymph node positivity (p = 0.03), and patients undergoing axillary lymph node dissection (p = 0.01). BCS using the sector resection technique has a low re-excision rate for positive margins. Younger patients and aggressive tumour biology are important predictive risk factors for positive margins.

Re-Excision Rates in Breast-Conserving Surgery for Invasive Breast Cancer after Neoadjuvant Chemotherapy with and without the Use of a Radiopaque Tissue Transfer and X-ray System

Background: Significant re-excision rates in breast-conserving surgery (BCS) after neoadjuvant systemic chemotherapy may result from difficulties in defining the surgical target particularly in cases with excellent treatment response. Devices allowing an exact topographic localisation of the lesion in the resected tissue could reduce re-excision rates by optimising the intraoperative detection of involved margins. Methods: 80 patients with invasive breast cancer receiving BCS after neoadjuvant chemotherapy were included in this non-randomized case-control study. 40 patients with specimen radiography performed in a standard approach (control group) were compared to 40 patients with use of a radiopaque tissue transfer system (study group). Results: 19/80 (23.75%) patients required re-excision because of involved margins; among those, 14/40 (35%) were in the control group and 5/40 (12.5%) in the study group. The association between the use of the radiopaque tissue transfer system and the lower re-excision rate was statistically significant (p = 0.023). Conclusion: Our analysis provides a rationale for the routine use of a radiopaque tissue transfer system for specimen radiography in BCS after neoadjuvant chemotherapy for invasive breast cancer in order to reduce re-excision rates.

25. Magseed for Localisation of Impalpable Breast Cancers is Associated with High Patient Satisfaction and Lower Re-Excision Rates

25. Magseed for Localisation of Impalpable Breast Cancers is Associated with High Patient Satisfaction and Lower Re-Excision Rates

Neoadjuvant endocrine therapy for ER+ DCIS reduces the size of disease and allows BCS with a low re-excision rate

Neoadjuvant endocrine therapy for ER+ DCIS reduces the size of disease and allows BCS with a low re-excision rate

Abstract P2-12-06: Re-excision rates in breast conserving surgery for invasive breast cancer after neoadjuvant chemotherapy with and without the use of a radiopaque tissue transfer and X-ray system

Abstract Background: Published re-excision rates after breast conserving surgery for invasive breast cancer vary between 20 and 50%. In patients after neoadjuvant chemotherapy even higher re-excision rates may result from difficulties in defining the surgical target particularly in cases with excellent treatment response. Specimen radiography is reducing re-excision rates, however, defining involved margins is often difficult using standard approaches. Devices allowing horizontal and vertical examination and an exact topographic localization of the lesion in the resected tissue could reduce re-excision rates by an intraoperative detection of involved margins. Methods: 80 patients with invasive breast cancer receiving breast conserving surgery after neoadjuvant chemotherapy and an indication for wire marking by mammography were included in this analysis. All tumors were marked with titanium clips prior to chemotherapy. In 40 patients specimen radiography was performed in a standard approach (control group), in 40 patients a tissue transfer and X-ray system based on a non-radiopaque board with radiopaque topographic markers and a stand for cranio-caudal X-rays was used (study group). A univariate analysis was carried out to evaluate the association between the use of the radiopaque tissue transfer system and the re-excision rate using a logistic regression model. Calculations were performed using the XLSTAT Biomed Software (Version 19.03, Addinsoft, NY, USA.). Results: 19/80 patients (23.75%) required re-excision because of involved margins; among those patients, 14/40 (35%) were in the control group and 5/40 (12.5%) in the study group. The association between the use of the radiopaque tissue transfer system and the lower re-excision rate was statistically significant (p=0.023). Conclusion: Our analysis provides a rationale for the use of a radiopaque tissue transfer system for specimen radiography in breast conserving surgery after neoadjuvant chemotherapy for invasive breast cancer in order to reduce re-excision rates. Based on these results we are planning a study including also patients receiving primary surgery. Citation Format: Kolberg H-C, Akpolat-Basci L, Stephanou M, Wetzig S, Cubuk Y, Gerharz J, Liedtke C. Re-excision rates in breast conserving surgery for invasive breast cancer after neoadjuvant chemotherapy with and without the use of a radiopaque tissue transfer and X-ray system [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-12-06.

The impact of preoperative magnetic resonance imaging and lumpectomy cavity shavings on re-excision rate in pure ductal carcinoma in situ-A single institution's experience.

The impact of preoperative magnetic resonance imaging (pMRI) and cavity shave margins (CSM) on re-excision rate (RR) in DCIS is unclear. We investigated whether either modality was associated with RR in DCIS. This is a single-institution retrospective study of 295 women undergoing breast conservation surgery for pure DCIS (2010-2013). CSM were the systematic resection of 4-6 margins during lumpectomy whereas selective shave margins (SSM) were the selective resection of 1-3 margins. Patient demographics and clinical characteristics were abstracted. RR was analyzed according to the use of pMRI, SSM, or CSM with respect to three high-volume breast surgeons at our institution. RR was not associated with the use of pMRI (P = 0.87). Any shave margins (P = 0.05), DCIS size (P < 0.001), and DCIS grade (P = 0.14) associated with a lower RR. Of our high-volume surgeons, RR was lower for Surgeon A (P = 0.02). Multivariate analyses showed larger DCIS (OR 1.35, P = 0.005) and practices specific to surgeons B (OR 3.23, P = 0.04) and C (OR 3.57, P = 0.04) increased re-excision odds. SSM/CSM and pMRI use varied among surgeons. Our results suggested the routine use of CSM, not pMRI, could lower re-excision rate, which highlighted a quality improvement opportunity at our institution.

Oncoplastic round block technique has comparable operative parameters as standard wide local excision: a matched case-control study.

Although oncoplastic breast surgery is used to resect larger tumors with lower re-excision rates compared to standard wide local excision (sWLE), criticisms of oncoplastic surgery include a longer-albeit, well concealed-scar, longer operating time and hospital stay, and increased risk of complications. Round block technique has been reported to be very suitable for patients with relatively smaller breasts and minimal ptosis. We aim to determine if round block technique will result in operative parameters comparable with sWLE. Breast cancer patients who underwent a round block procedure from 1st May 2014 to 31st January 2016 were included in the study. These patients were then matched for the type of axillary procedure, on a one to one basis, with breast cancer patients who had undergone sWLE from 1st August 2011 to 31st January 2016. The operative parameters between the 2 groups were compared. 22 patients were included in the study. Patient demographics and histologic parameters were similar in the 2 groups. No complications were reported in either group. The mean operating time was 122 and 114 minutes in the round block and sWLE groups, respectively (P=0.64). Length of stay was similar in the 2 groups (P=0.11). Round block patients had better cosmesis and lower re-excision rates. A higher rate of recurrence was observed in the sWLE group. The round block technique has comparable operative parameters to sWLE with no evidence of increased complications. Lower re-excision rate and better cosmesis were observed in the round block patients suggesting that the round block technique is not only comparable in general, but may have advantages to sWLE in selected cases.