Lumpectomy Cases Research Articles

Initial Experience Using Magseed for Breast Lesion Localization Compared With Wire-Guided Localization: Analysis of Volume and Margin Clearance Rates.

Detection of nonpalpable lesions requiring surgical intervention has increased during the past several decades. Techniques have evolved to help surgeons locate lesions in the operating room. Disadvantages of wire localization has led to the use of new approaches for surgical guidance. Magnetic seeds have been suggested to improve workflow and cosmetic result. This retrospective cohort study analyzed consecutive patients undergoing lumpectomy or excisional biopsy with the guidance of wire localization or magnetic seeds. The optimal and total resected volumes were calculated from pathology records, and the calculated resection volumes were compared by localization approach. Margin positivity and need for reoperation were reviewed and compared. Each group included 148 patients. The majority were treated with lumpectomy and did not undergo preoperative chemotherapy. The operative characteristics did not vary by group. Considering only lumpectomy cases, total volume resected (13.7 vs. 17.1; p = 0.003) and calculated resection ratios (1.8 vs. 2.5; p = 0.02) were significantly lower in the magnetic seed group. The rates of positive margins (10% vs. 14%) and reoperation (12.8% vs. 17.3%) were non-significantly lower than in the wire localization cases. Magnetic seeds were successfully used for lesion localization in this cohort. Pathologic examination of specimens suggested that the surgeons were able to remove closer to optimal volumes of tissue than those using wire-guided intervention. Removal of less tissue did not result in higher rates of margin positivity or a need for re-intervention to achieve negative margin status. Magnetic seeds are a feasible and non-inferior approach that overcomes many drawbacks of other localization methods.

Trends in Peripheral Nerve Block Usage in Mastectomy and Lumpectomy: Analysis of a National Database From 2010 to 2018.

Compared to general anesthesia, regional anesthesia confers several benefits including improved pain control and decreased postoperative opioid consumption. While the benefits of peripheral nerve blocks (PNB) have been well studied, there are little epidemiological data on PNB usage in mastectomy and lumpectomy procedures. The primary objective of our study was to assess national trends of the annual proportion of PNB use in breast surgery from 2010 to 2018. We also identified factors associated with PNB use for breast surgery. We identified lumpectomy and mastectomy surgical cases with and without PNB between 2010 and 2018 using the Anesthesia Quality Institute National Anesthesia Clinical Outcomes Registry (AQI NACOR). We modeled the nonlinear association between year of procedure and PNB use with segmented mixed-effects logistic regression clustered on facility identifier. The association between PNB use and year of procedure, age, sex, American Society of Anesthesiologists physical status (ASA PS), facility type, facility region, weekday, and tissue expander use was also modeled using mixed-effects logistic regression. Of the 189,854 surgical cases from 2010 to 2018 that met criteria, 86.2% were lumpectomy cases and 13.8% were mastectomy cases. The proportion of lumpectomy cases with PNB was <0.1% in 2010 and increased each subsequent year to 1.9% in 2018 (trend P < .0001). The proportion of mastectomy cases with PNB was 0.5% in 2010 and 13% in 2018 (trend P < .0001). The year 2014 was the breakpoint selected for segmented regression. Before 2014, the odds of PNB among the mastectomy cases was not significantly different from year to year. After 2014, the odds of PNB increased by 2.24-fold each year (95% confidence interval [CI], 2.00-2.49; P < .001); interaction test for pre-2014 versus post-2014 was P < .001. Similar trends were seen in the lumpectomy cases, where after 2014, the odds of PNB increased by 2.03-fold (95% CI, 1.81-2.27; P < .001); interaction test for pre-2014 versus post-2014 was P < .001. In the mastectomy cohort, year of procedure ≥2014, female sex, facility region, and tissue expander use were associated with higher odds of PNB. For lumpectomy cases, year of procedure ≥2014 and facility region were associated with higher odds of PNB use. We found increased annual utilization of PNB for mastectomy and lumpectomy since 2010, although absolute prevalence is low. PNB use was associated with year of procedure for both lumpectomy and mastectomy, particularly post-2014.

The Impact of Breast Lumpectomy Tray Utilization on Cost Savings

BackgroundRight-sizing instrument trays reduce processing and replacement costs, physical strain, and turnover times. Historically, a 98-instrument head and neck tray has been used for breast lumpectomy cases at our institution. Observations revealed that many instruments on the tray were not used during the breast cases. With the significant number of surgical breast lumpectomies performed annually, tray downsizing could significantly reduce costs and physical strain. MethodsSurgical technicians identified instruments needed for a standard breast lumpectomy. Breast surgeons reviewed the list and made final recommendations. Three of 13 existing head and neck trays were converted to breast lumpectomy trays. The number of breast lumpectomies in 2017 was pulled from the institution's health information system. Instrument quantities were verified using instrument management software. Weights were taken on a digital scale, and processing cost was estimated by a consultant. ResultsThe new breast trays included 51 instruments rather than the standard 98-instrument trays. Reprocessing cost decreased from $49.98 to $26.01. With 449 breast lumpectomies performed at the institution in 2017, the annual reprocessing savings totaled $10,763. The tray weight was reduced from 27 to 16 pounds. Setup time decreased from 7 to 4 min per use (22.5 h saved annually). ConclusionsDownsizing from a head and neck tray to a specific breast lumpectomy tray demonstrated a reduction in reprocessing cost, tray weight, and setup time. Lighter trays allow for safer handling and transport by surgical personnel. In the current health-care environment, it is important to maximize operating room efficiency and minimize cost.

Factors Associated With Positive Margins in Women Undergoing Breast Conservation Surgery

ObjectiveTo identify factors predicting positive margins at lumpectomy prompting intraoperative reexcision in patients with breast cancer treated at a large referral center. Patients and MethodsWe reviewed all breast cancer lumpectomy cases managed at our institution from January 1, 2012, through December 31, 2013. Associations between rates of positive margin and patient and tumor factors were assessed using χ2 tests and univariate and adjusted multivariate logistic regression, stratified by ductal carcinoma in situ (DCIS) or invasive cancer. ResultsWe identified 382 patients who underwent lumpectomy for definitive surgical resection of breast cancer, 102 for DCIS and 280 for invasive cancer. Overall, 234 patients (61.3%) required intraoperative reexcision for positive margins. The reexcision rate was higher in patients with DCIS than in those with invasive disease (78.4% [80 of 102] vs 56.4% [158 of 280]; univariate odds ratio, 2.80; 95% CI, 1.66-4.76; P<.001). Positive margin rates did not vary by patient age, surgeon, estrogen receptor, progesterone receptor, or ERBB2 status of the tumor. Among the 280 cases of invasive breast cancer, the only factor independently associated with lower odds of margin positivity was seed localization vs no localization (P=.03). ConclusionDuctal carcinoma in situ was associated with a higher rate of positive margins at lumpectomy than invasive breast cancer on univariate analysis. Within invasive disease, seed localization was associated with lower rates of margin positivity.

Abstract P1-11-08: Tumor and procedural factors associated with positive margins at lumpectomy in women undergoing breast conservation surgery

Abstract Background: Negative margins are important in decreasing risk of local recurrence after breast conservation surgery. Further, positive margins on final pathology require a second operation, burdening patients and increasing costs. We identified factors predicting positive margins at lumpectomy prompting intraoperative re-excision in a large referral center. Methods With IRB approval we reviewed all breast cancer lumpectomy cases from January 2012 to December 2013. Associations between rates of positive margin (defined as tumor at ink) and patient and tumor factors were assessed using chi square tests and univariate and adjusted multivariable logistic regression, overall and stratified by DCIS or invasive cancer. Results 385 patients (105 DCIS and 280 invasive disease) were identified. Overall positive margin rate at lumpectomy requiring intraoperative re-excision was 62.3% and was higher in DCIS than in invasive disease (78.1% vs 56.4%, OR=2.78, p=0.001). Positive margin rates did not vary by surgeon, patient age, ER, PR or HER2 status of the tumor. On univariate analysis higher tumor grade was associated with a higher margin positive rate (grade 3 vs grade 1, OR=1.71, p=0.049). Within the 105 DCIS cases, no factors had statistically significantly different odds of positive margins on univariate or multivariable analysis. Within the 280 cases of invasive breast cancer, factors independently associated with lower odds of margin positivity were neoadjuvant chemotherapy (OR 0.30, p=0.037, relative to no neoadjuvant therapy) and seed localized excision (OR 0.24, p=0.03, relative to no localization). Multivariable Logistic Regression* Modeling DCISInvasive DiseaseVariableOdds RatioP-valueOdds RatioP-valueAge 50+ vs Age &amp;lt;502.860.111.590.23Grade 2 vs Grade 10.940.921.500.21Grade 3 vs Grade 13.250.121.580.37Estrogen Receptor Positive vs Negative3.950.221.640.42Progesterone Receptor Positive vs Negative0.840.871.110.84Her2 Positive vs Negative 1.270.68Stage T2 vs T1 2.540.45Stage T3 vs T1 2.180.69Ki67 &amp;lt;15% vs 15%+ 0.570.09Neoadjuvant Chemotherapy vs None 0.300.04Seed Localization vs No Localization 0.240.03Wire Localization vs No Localization 0.330.13Intraoperative Ultrasound vs No Localization 0.670.53*adjusted for individual surgeons (all p &amp;gt;0.05) Conclusion DCIS was associated with higher rate of positive margins at lumpectomy than invasive breast cancer. Within invasive disease, neoadjuvant chemotherapy and seed localization were associated with lower rates of margin positivity. Strategies to decrease positive margins would be best employed in cases of lumpectomy for DCIS and for invasive disease treated without neoadjuvant chemotherapy. Seed localization may be one strategy to lower positive margin rates. Citation Format: Boughey JC, Keeney MG, Glasgow AE, Keeney GL, Habermann EB. Tumor and procedural factors associated with positive margins at lumpectomy in women undergoing breast conservation surgery [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-11-08.

Abstract P1-11-02: A comparison of models (physician, the Van Nuys prognostic index, the Memorial-Sloan-Kettering Cancer Center DCIS nomogram)to predict ipsilateral breast events in patients with ductal carcinoma in situ (DCIS) of the breast after breast-conserving surgery failed to replicate results of the oncotype DCIS recurrence score

Abstract Purpose: To compare ipsilateral breast event (IBE) risks in patients with DCIS of the breast post-lumpectomy, as estimated by breast radiation oncologists, the Van Nuys Prognostic Index (VNPI) studies, the Memorial Sloan Kettering Cancer Center (MSK) DCIS nomogram, and the 12-gene DCIS Recurrence Score assay. Materials/Methods: 12-gene DCIS Recurrence Score of 91 DCIS lumpectomy cases were identified from our practice. Clinicopathologic factors (excluding DCIS score) were summarized for blinded review. 3 radiation oncologists independently estimated the 10-year IBE risk and rated the impact of age/menopausal status, tumor morphology, tumor span, and margin width. Corresponding VNPI and MSK nomogram estimates were generated. Differences and correlations between the IBE estimates and clinicopathologic factors were evaluated with univariate and multivariate analysis. Results: Median age was 60, 25% margins &amp;lt; 3 mm, 48% DCIS span &amp;gt; 10 mm, 48% would have been ineligible for E5194. All comparisons were initially examined for similarity (non-significant differences) and susequently tested for a significant correlation. In three possible physician comparisons only 1 (AA-CL) had similar IBE estimates and strong correlation (r=0.792). Comparison of physicians to either VNPI nomogram or MSK DCIS calculator had similar estimates with strong correlation in only 2 of 6 possible comparisons in the all cases and the E5194 eligible patient cohorts respectively; and in 1 of 6 comparisons in the E5194 ineligible cohort. The DCIS Recurrence Score showed no strong correlation in regard to similar IBE estimates for any comparisons including either physicians, VNPI nomogram or MSK DCIS calculator. Tumor size was highly correlated with all physician IBE estimates (r = 0.547 to 0.799), while margin size showed moderate to high inverse correlations (r = -0.324 to -0.619). All 3 physicians rated margin width as having the most impact on their IBE risk estimates, then tumor morphology and tumor span. Source of EstimateAll Cases (n = 91)E5194 Eligible (n = 47)E5194 Ineligible (n = 44)DCIS Score15.1%, 5.3 (14.0-16.2)14.2%, 4.8 (12.8-15.6)16.1%, 5.7 (14.3-17.8)MSK DCIS Nomogram (Rudloff et al., 2010)18.8%, 7.7 (17.2-20.4)23.4%, 18.6 (19.6-27.3)16.1%, 4.1 (14.9-17.3)21.7%, 9.4 (18.8-24.6)VNPI studies23.4%, 18.6 (19.6-27.3)15.6%, 15.5 (11.0-20.1)31.9%, 18.1 (26.4-37.4)AA18.9%, 14.1 (16.0-21.9)11.7%, 8.8 (9.1-14.3)26.6%, 14.7 (22.2-31.1)CL19.9%, 11.8 (17.5-22.4)14.5%, 6.6 (12.5-16.4)25.8%, 13.3 (21.7-29.8)DC26.8%, 13.9 (23.9-29.7)19.8%, 5.9 (18.1-21.6)34.2%, 16.1 (29.3-39.1) Conclusion: IBE risk estimates for this cohort of DCIS cases vary significantly among commonly available clinical predictive tools and individual physician estimates. Surgical margins and tumor size continue to factor prominently in physician decision algorithms. In our observations, neither the VNPI nomogram, MSK DCIS calculator nor physician IBE risk estimates have similar values with strong enough correlation to reliably replicate the DCIS Recurrence Score. Citation Format: Leonard C, Lei R, Antell A, Nowels M, Fryman S, Howell K, Dennis C. A comparison of models (physician, the Van Nuys prognostic index, the Memorial-Sloan-Kettering Cancer Center DCIS nomogram)to predict ipsilateral breast events in patients with ductal carcinoma in situ (DCIS) of the breast after breast-conserving surgery failed to replicate results of the oncotype DCIS recurrence score [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-11-02.

Economic Implications of Widespread Expansion of Frozen Section Margin Analysis to Guide Surgical Resection in Women With Breast Cancer Undergoing Breast-Conserving Surgery.

In the current health care environment, cost effectiveness is critically important in policy setting and care of patients. This study performed a health economic analysis to assess the implications to providers and payers of expanding the use of frozen section margin analysis to minimize reoperations for patients undergoing breast cancer lumpectomy. A health care economic impact model was built to assess annual costs associated with breast lumpectomy procedures with and without frozen section margin analysis to avoid reoperation. If frozen section margin analysis is used in 20% of breast lumpectomies and under a baseline assumption that 35% of initial lumpectomies without frozen section analysis result in reoperations, the potential annual cost savings are $18.2 million to payers and $0.4 million to providers. Under the same baseline assumption, if 100% of all health care facilities adopted the use of frozen section margin analysis for breast lumpectomy procedures, the potential annual cost savings are $90.9 million to payers and $1.8 million to providers. On the basis of 10,000 simulations, use of intraoperative frozen section margin analysis yields cost saving for payers and is cost neutral to slightly cost saving for providers. This economic analysis indicates that widespread use of frozen section margin evaluation intraoperatively to guide surgical resection in breast lumpectomy cases and minimize reoperations would be beneficial to cost savings not only for the patient but also for payers and, in most cases, for providers.

Outcomes associated with adjuvant radiation after lumpectomy for elderly women with T1-2N0M0 triple-negative breast cancer: SEER analysis.

39 Background: Adjuvant Radiation (RT) may be omitted for elderly women with early stage breast cancer having favorable estrogen receptor status, however in the setting of triple negative breast cancer (TNBC), less evidence exists to guide decision making. As some findings thus far have shown TNBC to have an increased recurrence rate, this is an important subject to address. The purpose of this study is to use the Surveillance, Epidemiology, and End Result (SEER) database to evaluate how the addition of adjuvant radiation affects the survival of women ages 70 and above with T1-2, N0, M0 TNBC that undergo Lumpectomy (L). Methods: Cases diagnosed from 2010-2011 were downloaded from the SEER Database. Inclusion criteria were ages 70 and above, with T1-2N0M0 TNBC. Kaplan meier curves calculated overall survival (OS) and disease specific survival (DSS) in months (m). Log-Rank tests were performed to compare survival. Cox multivariate regression was performed to calculate Hazard Ratios (HR) and control for confounding variables including neoadjuvant chemotherapy, number of lymph nodes sampled, age, laterality, grade, T stage, extent of surgery, existence of other cancers. Results: From 2010-2011, SEER contained 109,559 cases of breast cancer with recorded results of Her-2-neu (H2N) status. Combining other receptor values, showed 12,620 triple-negative, which was 12% of cases. Of these, 6980 (55%) had stage T1-2, N0, M0. Lumpectomy was used in 4002 of these cases. There were 974 lumpectomy cases of women aged 70 and above. RT was given in 662 (68%) cases. After 23 months, L+ RT was associated with improved OS at 98.2% compared to 85.6% for L only (p=&lt;0.001), as well as DSS at 99% for L+RT better than 94% for L only (p=0.003). Cox Regression showed radiation demonstrated improved OS (HR=0.14, p&lt;0.001) and DSS (0.14, p=0.01). Conclusions: The use of adjuvant RT after lumpectomy for elderly women with early stage TNBC was associated with improved OS and DSS. Noting the potential for selection bias in this study, future prospective study is required to define the management of early stage triple negative breast cancer.

The impact of use of an intraoperative margin assessment device on re-excision rates.

Historically there has been a high rate of surgical interventions to obtain clear margins for breast cancer patients undergoing breast conserving local therapy. An intraoperative margin assessment tool (MarginProbe) has been approved for use in the US since 2013. This study is the first compilation of data from routine use of the device, to assess the impact of device utilization on re-excision rates. We present a retrospective, observational, review from groups of consecutive patients, before and after the implementation of intraoperative use of the device during lumpectomy procedures. Lesions were localized by standard methods. The intraoperative margin assessment device was used on all circumferential margins of the main specimen, but not on any additional shavings. A positive reading by the device led to an additional shaving of the corresponding cavity location. Specimens were also, when feasible, imaged intra-operatively by X-ray, and additional shavings were taken if needed based on clinical assessment. For each surgeon, historical re-excision rates were established based on a consecutive set of patients from a time period proximal to initiation of use of the device. From March 2013 to April 2014 the device was routinely used by 4 surgeons in 3 centers. In total, 165 cases lumpectomy cases were performed. Positive margins resulted in additional re-excision procedures in 9.7% (16/165) of the cases. The corresponding historical set from 2012 and 2013 consisted of 186 Lumpectomy cases, in which additional re-excision procedures were performed in 25.8% (48/186) of the cases. The reduction in the rate of re-excision procedures was significant 62% (P < 0.0001). Use of an intraoperative margin assessment device contributes to achieving clear margins and reducing re-excision procedures. As in some cases positive margins were found on shavings, future studies of interest may include an analysis of the effect of using the device on the shavings intra-operatively.

P3-14-21: Neoadjuvant Therapy Response, Subtype and BRCA Status in an Underserved Population.

Abstract Background Preoperative (neoadjuvant) chemotherapy is typically used for larger operable breast cancer cases, and the degree of pathological response correlates with long term outcome. Therapeutic response also depends on biological and molecular subtype and is increasingly studied in the research setting to identify prognostic biomarkers and potential therapeutic targets. Little is known about the interactions of neoadjuvant response with biomarker subtypes and genetic predisposition in underserved and minority populations. Methods: IRB approval was obtained to capture demographic, clinicopathological and genetic testing data on patients diagnosed with invasive breast cancer and treated with preoperative chemotherapy and definitive surgery between 2005 and 2010 at Los Angeles County Medical Center, which serves a primarily Hispanic and indigent population. Treatment followed NCCN guidelines with the exception that not all patients with HER2+ disease received trastuzumab. Genetic counseling and testing has been available at this center since 2007. Pathological complete response (pCR) was defined as no residual invasive disease in breast or nodes. Chi-square or Fisher's Exact test was used to examine associations between pCR and clinical factors, and logistic regression analyses were applied to assess each variable's contribution to pCR. Results: Among 104 patients, of whom 79% were Hispanic, the overall pCR rate was 27%. Significantly higher pCR rates were seen in age ≥50, clinical N0, HER2+, triple negative, and lumpectomy cases. No differences in pCR rate was seen in Hispanics vs. others, Grade III vs. I and II or in the 9 BRCA mutations carriers among 45 tested compared to no mutation or those not tested. Of the 43 patients with HER2+ disease, the pCR rate was higher in the 32 patients who received trastuzumab (pCR 50.0 vs. 27.3%). Subset pCR rates and odds ratios (OR) of achieving pCR are shown below: Conclusions: In this underserved cohort, with 43% undergoing genetic testing, significantly higher pCR rates were seen in HER2+ and triple negative and lumpectomy cases, with a trend seen in older patients and smaller tumors. There was an unexpected trend of lower pCR rate seen in BRCA mutation carriers (pCR OR 0.33), albeit with small numbers. No differences were seen in Hispanic cases compared to other ethnicities. Further tissue analyses are planned to examine established and novel markers and to define exploratory markers that could be used for decision-making and target discovery in larger datasets within this population. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-14-21.

Relation between time-dose and local control of operable breast cancer treated by tumorectomy and radiotherapy or by radical radiotherapy alone.

67 patients with tumors 3 cm or less and with negative axilla, who had lumpectomy and radiotherapy, and 122 patients with larger tumors or clinically positive axilla, who had radical radiotherapy without prior lumpectomy, were evaluated at five years to determine the optimum dose for local control. 7000 rad in seven to eight weeks controlled 85% of lumpectomy cases, whereas 8000 rad in 81/2 weeks were required to control two-thirds of cases treated by radical irradiation alone. Subclinical (N0, N1a) and clinical disease (N1b) in the axilla was controlled, in a very high percentage, when 6000 and 7000 rad were delivered, respectively. Dose response curves were obtained for clinical disease in the breast and axilla. No such response was elicited for subclinical disease. Undifferentiated cancers had higher recurrence rates than well differentiated tumors. Radiation fibrosis in lumpectomy cases was insignificant, whereas 10% of radically irradiated patients had fibrosis of the breast.