Re-excision Rates Research Articles

Early Outcome of Superomedial Pedicle as Extreme Oncoplastic Procedure versus Modified Radical Mastectomy in Patients with Stage T3 Breast Cancer Not Responding to Neoadjuvant Chemotherapy

Abstract Background Breast cancer, according to national cancer institute, is the most common site of cancer in women in Egypt as it accounts for about 38.8% of total malignancies among Egyptian females; it is an important cause of mortality among women. Aim of the Work To assess the feasibility of extreme oncoplasty (achieving negative margins) for T3 breast cancer patients not responding to neoadjuvant chemotherapy by using a superomedial pedicle flap. Patients and Methods This study was conducted on 30 female patients with stage T3 breast cancer not responding to neoadjuvant chemotherapy with no skin involvement or upper medial quadrant tumor, with large breast size (cup D), accepting both intervention modalities and fit for both anesthesia and radiotherapy. It was performed at the (General Surgery Department) at Ain Shams University Hospitals and El Haram specialized Hospital starting from March 2020. Approval of the Ethical Committee and written informed consent from all participants were obtained. Patients were divided into two groups. Group A includes 15 patients underwent Modified radical mastectomy with axillary clearance. Group B includes 15 patients underwent Superomedial pedicle mammoplasty and axillary clearance. Results Superomedial pedicle mammoplasty is equivalent to modified radical mastectomy in terms of oncological safety, with advantages over mastectomy in terms of quality of life and esthetic outcomes. Thus, Extreme oncoplasty provides an alternative to Modified radical mastectomy, extends the scope of breast conservation, provides better clinical outcomes, and improves quality of life. Conclusion This study showed that superomedial pedicle mammoplasty technique is a feasible extreme oncoplastic approach for patients with large tumors and not responsive to neoadjuvant chemotherapy considered for Modified radical mastectomy with acceptable complication rates, negligible rates of reexcision and no early recurrence in 3 months period.

Intraoperative Ultrasound-Guided Conserving Surgery for Breast Cancer: No More Time for Blind Surgery.

Breast-conserving surgery (BCS) still remains a blind surgery despite all available tumor localization methods. Intraoperative ultrasound (IOUS) allows real-time visualization during all resection phases. This was a prospective observational cohort study conducted at the Veneto Institute of Oncology between January 2021 and June 2022. Patients with ductal carcinoma in situ, T1-2 invasive cancer, or post-neoadjuvant tumors, suitable for BCS, were recruited. All breast cancer lesion types were included, i.e. solid palpable, solid non-palpable, non-solid non-palpable, and post-neoadjuvant treatment residual lesions. Eligible participants were randomly assigned to either IOUS or traditional surgery (TS) in a 1:1 ratio. The main outcomes were surgical margin involvement, reoperation rate, closest margin width, main specimen and cavity shaving margin volumes, excess healthy tissue removal, and calculated resection ratio (CRR). Overall, 160 patients were enrolled: 80 patients were allocated to the TS group and 80 to the IOUS group. IOUS significantly reduced specimen volumes (16.8 cm3 [10.5-28.9] vs. 24.3 cm3 [15.0-41.3]; p=0.015), with wider closest resection margin width (2.0 mm [1.0-4.0] vs. 1.0 mm [0.5-2.0] after TS; p<0.001). Tumor volume to specimen volume ratio was significantly higher after IOUS (4.7% [2.5-9.1] vs. 2.9% [0.8-5.2]; p<0.001). IOUS yielded significantly better CRR (84.5% [46-120.8] vs. 114% [81.8-193.2] after TS; p<0.001), lower involved margin rate (2.5 vs. 15%; p=0.009) and reduced re-excision rate (2.5 vs. 12.5%; p=0.032). IOUS allows real-time resection margin visualization and continuous control during BCS. It showed clear superiority over TS in both oncological and surgical outcomes for all breast cancer lesion types. These results disfavor the paradigm of blind breast surgery.

Breast Magnetic Resonance Imaging for Preoperative Evaluation of Breast Cancer: A Systematic Review and Meta-Analysis.

Purpose: Preoperative breast magnetic resonance imaging (MRI) is known to detect additional cancers that are occult on mammography and ultrasound. There is debate as to whether these additional lesions affect clinical outcomes. The objective of this systematic review was to summarize the evidence on whether additional information on disease extent obtained with preoperative breast MRI in patients with newly diagnosed breast cancer affects surgical management, rates of recurrence, survival, re-excision, and early detection of bilateral cancer. Methods: Embase, MEDLINE, and Cochrane Central Register of Controlled Trials were searched until January 2021 (partial update July 2022) for studies comparing outcomes with versus without pre-operative MRI. Included were both randomized controlled trials and other comparative studies provided MRI and control groups had equivalent disease and patient characteristics or methods such as multivariable analysis or propensity score matching were used to control potential confounders. Results: The search resulted in 26,399 citations, of which 8 randomized control trials, 1 prospective cohort study, and 42 retrospective studies met the inclusion criteria. Use of MRI resulted in decreased rates of reoperations (OR = 0.73, 95% CI = 0.63 to 0.85), re-excisions (OR = 0.63, 95% CI = 0.45 to 0.89), and recurrence (HR = 0.77, 95% CI = 0.65 to 0.90). Increased detection of synchronous contralateral breast cancers led to a reduction in metachronous contralateral breast cancer (HR = 0.71, 95% CI = 0.59 to 0.85). Hazard ratios for recurrence-free and overall survival were 0.77 (95% CI = 0.53 to 1.12) and 0.89 (95% CI = 0.74 to 1.07). Conclusion: This systematic review indicates substantial benefits of pre-operative breast MRI in decreasing reoperations and recurrence.

Long-Term Patient-Reported Outcomes Comparing Oncoplastic Breast Surgery and Conventional Breast-Conserving Surgery: A Propensity Score-Matched Analysis.

Oncoplastic breast surgery (OBS) combines plastic surgery techniques with conventional breast-conserving surgery (BCS) and expands BCS eligibility. Limited data are available on patient-reported outcomes (PROs) after OBS. Here we compare long-term PROs after OBS and BCS utilizing the BREAST-Q. Women undergoing OBS or BCS between 2006 and 2019 who completed ≥ 1 long-term BREAST-Q survey 3-5 years postoperatively were identified. Baseline characteristics were compared between women who underwent OBS/BCS. Women who underwent OBS were paired with those who underwent BCS using 1:2 propensity matching [by age, body mass index (BMI), race, T stage, and multifocality]. BREAST-Q scores were compared preoperatively and 3-5 years postoperatively. A total of 297 patients were included for analysis (99 OBS/198 BCS). Women who underwent OBS were younger (p < 0.001) and had higher BMI (p = 0.005) and multifocal disease incidence (p = 0.004). There was no difference between groups in nodal stage, re-excision rates, axillary surgery, chemotherapy, endocrine therapy, or radiotherapy. After propensity matching preoperatively, women who underwent OBS reported lower psychosocial well-being (63 versus 100, p = 0.039) but similar breast satisfaction and sexual well-being compared with women who underwent BCS; however, only three patients who underwent BCS had preoperative BREAST-Q scores available for review. In long-term follow-up, women who underwent OBS reported lower psychosocial scores (74 versus 93, p = 0.011) 4 years postoperatively, but not at 5 years (76 versus 77, p = 0.83). There was no difference in long-term breast satisfaction or sexual well-being. Women who undergo OBS present with a larger disease burden and may represent a group of non-traditional BCS candidates; they reported similar long-term breast satisfaction and sexual well-being compared with women who undergo BCS. While women who underwent OBS reported lower psychosocial well-being scores preoperatively and during a portion of the follow-up period, this difference was no longer seen at 5 years postoperatively.

Simultaneous Symmetry Procedure in Patients Undergoing Oncoplastic Breast-Conserving Surgery: An Evaluation of Patient Desire and Revision Rates.

In the era of oncoplastic breast conserving-surgery (OBCS), cosmetic outcomes and the desire for symmetry have become essential elements of the surgical management of breast cancer (BC). The timing of contralateral symmetry procedures remains a controversial topic. Simultaneous symmetry procedures (SSP) in OBCS have not been routinely offered due to the perceived risk of delayed asymmetry, potentially increasing the need for delayed cosmetic revision. This study evaluates the rate of revision after SSP in patients undergoing OBCS. We reviewed our institutional prospectively maintained database identifying all BC patients treated surgically since our introduction of oncoplastic surgery in 2018. We routinely offer SSP when appropriate. Descriptive statistics evaluated oncoplastic surgical techniques, SSP offerings and procedures, perioperative complications, and revision rates after treatment completion. Between 2018 and 2022, 485 breast cancer patients underwent partial mastectomy, and 396 (82%) underwent OBCS. Of the 313 patients offered SSP, 272 (87%) accepted. The margin reexcision rate of this cohort was 20%. Of the 272 patients with SSP, 152 (56%) underwent intraoperative radiation therapy (IORT), and 105 (39%) had adjuvant external beam radiation therapy. Three patients (1%) experienced complications involving the symmetry side. No patients with complications experienced a delay in adjuvant therapies or requested cosmetic revisions. Three patients (1%) desired surgical revisions due to asymmetry. Symmetry procedures at the time of OBCS are widely accepted by patients and rarely require delayed cosmetic revision. Simultaneous symmetry procedures should be routinely discussed with patients during the surgical planning of OBCS.

Magnetic seed versus skin tattoo localization of non-palpable breast lesions: a single institution cohort study.

The objective of this retrospective study was to investigate the accuracy and feasibility of magnetic seed compared to skin tattoo in preoperative localization of impalpable breast lesions in terms of accuracy of placement, re-excision and positive margins rates, and breast/surgical specimen volume ratio. We retrospectively analyzed 77 patients who underwent breast conservative surgery in our center from November 2020 to November 2021, with previous localization with skin tattoo or magnetic seed. Thirty-seven magnetic seeds were placed in 36 patients (48.6%) and 40 skin tattoos were performed in the remaining cases (51.4%). The seeds were placed correctly at the two-view mammogram acquired after the insertion in 97.6% (36/37) of cases. With both methods, 100% of the index lesions were completely removed and found in the surgical specimen. The reported re-excision rate was 0% for both groups. A significant difference was observed in the volume of breast parenchyma removed between the two groups, inferior in the seed group (p = 0.046), especially in case of voluminous breasts (p = 0.003) and small lesions (dimension < 8mm, p = 0.019). Magnetic seed is a non-radioactive localization technique, feasible to place, recommended in case of non-palpable breast lesions, saving the breast parenchyma removed compared with skin tattoo, without reducing the accuracy. Our findings contribute to the current evidence on preoperative localization techniques for non-palpable breast lesions, highlighting the efficacy of magnetic seed localization for deep and small lesions. • Magnetic seed is a non-radioactive technique for the preoperative localization of non-palpable breast lesions studied in comparison with skin tattoo. • Magnetic seed is feasible to place in terms of post-placement migration and distance from the target lesion. • Magnetic seed is recommended in case of non-palpable breast lesions, saving the breast parenchyma removed without reducing the accuracy.

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.

A Retrospective Study of Re-excised Skin Cancers in a Pathology Center.

Surgical re-excision is the recommended treatment for the complete removal of incompletely excised skin cancers (SCs), but it may not always lead to this goal. In the present study, the re-excision rate and the presence of residual tumors in re-excised SCs were evaluated. In this retrospective descriptive study, the pathological archives of a hospital center were examined for incompletely excised tumors. Out of the 96 incompletely excised tumors, 19 cases (19.8%) underwent re-excision, of which residual tumors were observed again in 7 cases (36.8%). The highest rate of residual tumor was found in the cheek (66.66%), and the involvement with tumor remnants of both margins combined was greater than the involvement of each of the lateral and deep margins alone. Collecting and reporting of surgical results of re-excised tumors may assist clinicians in determining the patient's condition and making appropriate decisions to increase the success rate of reoperations.

Radiofrequency localization of nonpalpable breast cancer in a multicentre prospective cohort study: feasibility, clinical acceptability, and safety

PurposeIn breast conserving surgery, accurate lesion localization is essential for obtaining adequate surgical margins. Preoperative wire localization (WL) and radioactive seed localization (RSL) are widely accepted methods to guide surgical excision of nonpalpable breast lesions but are limited by logistical challenges, migration issues, and legislative complexities. Radiofrequency identification (RFID) technology may offer a viable alternative. The purpose of this study was to evaluate the feasibility, clinical acceptability, and safety of RFID surgical guidance for localization of nonpalpable breast cancer.MethodsIn a prospective multicentre cohort study, the first 100 RFID localization procedures were included. The primary outcome was the percentage of clear resection margins and re-excision rate. Secondary outcomes included procedure details, user experience, learningcurve, and adverse events.ResultsBetween April 2019 and May 2021, 100 women underwent RFID guided breast conserving surgery. Clear resection margins were obtained in 89 out of 96 included patients (92.7%), re-excision was indicated in three patients (3.1%). Radiologists reported difficulties with the placement of the RFID tag, partially related to the relatively large needle-applicator (12-gauge). This led to the premature termination of the study in the hospital using RSL as regular care. The radiologist experience was improved after a manufacturer modification of the needle-applicator. Surgical localization involved a low learning curve. Adverse events (n = 33) included dislocation of the marker during insertion (8%) and hematomas (9%). The majority of adverse events (85%) occurred using the first-generation needle-applicator.ConclusionRFID technology is a potential alternative for non-radioactive and non-wire localization of nonpalpable breast lesions.

Real de-escalation or escalation in disguise?

The past two decades have seen an unprecedented trend towards de-escalation of surgical therapy in the setting of early BC, the most prominent examples being the reduction of re-excision rates for close surgical margins after breast-conserving surgery and replacing axillary lymph node dissection by less radical procedures such as sentinel lymph node biopsy (SLNB). Numerous studies confirmed that reducing the extent of surgery in the upfront surgery setting does not impact locoregional recurrences and overall outcome. In the setting of primary systemic treatment, there is an increased use of less invasive staging strategies reaching from SLNB and targeted lymph node biopsy (TLNB) to targeted axillary dissection (TAD). Omission of any axillary surgery in the presence of pathological complete response in the breast is currently being investigated in clinical trials. On the other hand, concerns have been raised that surgical de-escalation might induce an escalation of other treatment modalities such as radiation therapy. Since most trials on surgical de-escalation did not include standardized protocols for adjuvant radiotherapy, it remains unclear, whether the effect of surgical de-escalation was valid in itself or if radiotherapy compensated for the decreased surgical extent. Uncertainties in scientific evidence may therefore lead to escalation of radiotherapy in some settings of surgical de-escalation. Further, the increasing rate of mastectomies including contralateral procedures in patients without genetic risk is alarming. Future studies of locoregional treatment strategies need to include an interdisciplinary approach to integrate de-escalation approaches combining surgery and radiotherapy in a way that promotes optimal quality of life and shared decision-making.

MELODY (Methods for Localization of Different Types of Breast Lesions): A prospective non-interventional multicenter cohort study to evaluate different imaging-guided methods for localization of malignant breast lesions (EUBREAST-4/iBRA-NET).

TPS626 Background: In the last decades, the proportion of breast cancer patients receiving breast-conserving surgery has increased, reaching 70-80% in developed countries. In case of non-palpable lesions, surgical excision requires some form of breast localization. While wire-guided localization has long been considered gold standard, it carries several limitations, including logistical difficulties, the potential for displacement and patient discomfort, and re-excision rates reaching 21%. Other techniques (radioactive seed or radio-occult lesion localization, intraoperative ultrasound, magnetic, radiofrequency and radar localization) have been developed with the aim of overcoming these disadvantages. However, comparative data on the rates of successful lesion removal, negative margins and re-operations are limited. In the majority of studies, the patient’s perspective with regard to discomfort and pain level has not been evaluated. The aim of MELODY is to evaluate different imaging-guided localization methods with regard to oncological safety, patient-reported outcomes, and surgeon and radiologist satisfaction. Methods: The EUBREAST and the iBRA-NET have initiated the MELODY study to assess breast localization techniques and devices from several perspectives (NCT05559411, http://melody.eubreast.com ). MELODY is a prospective intergroup cohort study which enrolls female and male pts. requiring breast-conserving surgery and imaging-guided localization for invasive breast cancer or DCIS. Multiple or bilateral lesions and neoadjuvant chemotherapy are allowed. Primary outcomes are: 1) Intended target lesion and/or marker removal, independent of margin status on final histopathology, and 2) Negative resection margin rates at first surgery. Secondary outcomes are, among others: rates of second surgery and secondary mastectomy, Resection Ratio (defined as actual resection volume divided by the calculated optimum specimen volume), duration of surgery, marker dislocation rates, rates of marker placement or localization failure, comparison of patient-reported outcomes, rates of “lost markers” and diagnostician/radiologist’s and surgeon’s satisfaction as well as the health economic evaluation of the different techniques. Target accrual: 7,416 patients. Enrollment started in January 2023. The study will be conducted in 20 countries and is supported by the Oncoplastic Breast Consortium (OPBC), AWOgyn, AGO-B and SENATURK. Clinical trial information: NCT05559411 .

A Comparison of Spectroscopy and Imaging Techniques Utilizing Spectrally Resolved Diffusely Reflected Light for Intraoperative Margin Assessment in Breast-Conserving Surgery: A Systematic Review and Meta-Analysis.

Up to 19% of patients require re-excision surgery due to positive margins in breast-conserving surgery (BCS). Intraoperative margin assessment tools (IMAs) that incorporate tissue optical measurements could help reduce re-excision rates. This review focuses on methods that use and assess spectrally resolved diffusely reflected light for breast cancer detection in the intraoperative setting. Following PROSPERO registration (CRD42022356216), an electronic search was performed. The modalities searched for were diffuse reflectance spectroscopy (DRS), multispectral imaging (MSI), hyperspectral imaging (HSI), and spatial frequency domain imaging (SFDI). The inclusion criteria encompassed studies of human in vivo or ex vivo breast tissues, which presented data on accuracy. The exclusion criteria were contrast use, frozen samples, and other imaging adjuncts. 19 studies were selected following PRISMA guidelines. Studies were divided into point-based (spectroscopy) or whole field-of-view (imaging) techniques. A fixed-or random-effects model analysis generated pooled sensitivity/specificity for the different modalities, following heterogeneity calculations using the Q statistic. Overall, imaging-based techniques had better pooled sensitivity/specificity (0.90 (CI 0.76-1.03)/0.92 (CI 0.78-1.06)) compared with probe-based techniques (0.84 (CI 0.78-0.89)/0.85 (CI 0.79-0.91)). The use of spectrally resolved diffusely reflected light is a rapid, non-contact technique that confers accuracy in discriminating between normal and malignant breast tissue, and it constitutes a potential IMA tool.

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.

O074 Localisation using multiple magnetic seeds in unilateral breast surgery: a report of clinical and radiological outcomes in a tertiary breast cancer centre

Abstract Introduction Magnetic seeds (Magseeds) are becoming increasingly used as a method of localising non-palpable breast lesions. The cost effectiveness and reduced scheduling conflicts in comparison with wire localization has led to increased popularity in recent years. There's a paucity of data on outcomes when using multiple magseeds in one breast. In this study, we assess the radiological, operative and pathological outcomes of inserting multiple magseeds in the same breast. Methods A retrospective analysis of all magseed guided excisions preformed at the MMUH breast surgery department between January 2020 and December 2022. 40 patients with more than one magseed inserted unilaterally were included. Primary outcome measures were successful excision of lesion(s) and magseed retrieval. Secondary outcomes included re-excision rate and perioperative complications. Results The mean distance between magseeds was 48.3 and 42.5 mm on ML and CC views respectively. 9/40 used magseeds for bracketing while the rest used for excision of discrete lesions. Mean operative time was 56.65 minutes and 55% of the procedures were wide local excisions. There was no reported difficulties identifying magseeds intra-operatively or in the specimen mammogram. The mean specimen size is 33.42 mm while the mean size of the final lesion is 15.49 mm. Invasive ductal carcinoma was the commonest pathological outcome. The rate of positive margins was 20% and re-excision was 15%. One patient proceeded to completion mastectomy. Conclusion Multiple magseed localisation is a feasible, safe and effective method when utilized in bracketing a unifocal lesion or separate lesion excisions in unilateral breast surgery.

Predictors of residual disease after breast conservation surgery for ductal carcinoma in situ: A retrospective study.

Breast-conserving therapy is the standard of care for ductal carcinoma in situ (DCIS). Debate on what constitutes a satisfactory margin persists. This study aimed to identify predictors of residual disease at re-excision. This is a population-based retrospective cohort study of women with DCIS who underwent a lumpectomy between 2007 and 2017 in Manitoba, with close (≤2 mm) or positive margins that led to re-excision. The DCIS re-excision rate was 29.3% for 1001 patients. 63.2% of patients were found to have residual disease on re-excision. On univariable analysis, the size, margin status, number of positive margins, type of second surgery, and Van Nuys Prognostic Index score were associated with residual disease on re-excision. The size of DCIS and the number of positive margins remained statistically significant on multivariable analysis. Re-excision should be rationalized by considering the predictors of residual disease in conjunction with other factors.

Evaluating the impact of radiofrequency spectroscopy on reducing reoperations after breast conserving surgery: A meta-analysis.

The benefits of breast conserving surgery for breast cancer patients are well established. To achieve adequate margins of excision, intraoperative management of breast margins is a critical factor through reducing reoperation for inadequate positive margin excision and associated morbidity and cost. Radiofrequency spectroscopy is a technology that could significantly reduce positive margins when used intraoperatively as an adjunct to other margin management methods. A meta-analysis was completed with 10 publications comparing use of radiofrequency spectroscopy technology (MarginProbe) with standard margin assessment procedures. Three randomized controlled studies and seven retrospective studies comparing MarginProbe to historical controls were included. The primary endpoint was reduction of re-excision rates. Statistical significance level was set at the two-sided 5% level corresponding to two-sided 95% confidence intervals (CIs) of the pooled relative risk estimates. A total of 2335 patients from 10 publications were included in this meta-analysis. The overall relative reduction in re-excision rate was 0.49 (95% CI: 0.38-0.64, p < 0.001). Statistical methods were used to examine publication bias. Despite the limited randomized controlled trials available comparing radiofrequency spectroscopy to standard operation procedures, the data from the 10 studies demonstrate a statistically significant reduction in re-excision rate of 49% for MarginProbe usage, currently the only technology indicated for intraoperative identification of breast cancer tissue at the lumpectomy specimen margin.

The Impact of an Electromagnetic Seed Localization Device Versus Wire Localization on Breast-Conserving Surgery: A Matched-Pair Analysis.

For breast-conserving surgery (BCS), several alternatives to wire localization (WL) have been developed. The newest, electromagnetic seed localization (ESL), provides three-dimensional navigation using the electrosurgical tool. This study assessed operative times, specimen volumes, margin positivity, and re-excision rates for ESL and WL. Patients who had ESL-guided breast-conserving surgery between August 2020 and August 2021 were reviewed and matched one-to-one with patients who had WL based on surgeon, procedure type, and pathology. Variables were compared between ESL and WL using Wilcoxon rank-sum and Fisher's exact tests. The study matched 97 patients who underwent excisional biopsy (n = 20) or partial mastectomy with (n = 53) or without (n = 24) sentinel lymph node biopsy (SLNB) using ESL. The median operative time for ESL versus WL for lumpectomy was 66 versus 69 min with SLNB (p = 0.76) and 40 versus 34.5 min without SLNB (p = 0.17). The median specimen volume was 36 cm3 using ESL versus 55 cm3 using WL (p = 0.001). For the patients with measurable tumor volume, excess tissue was greater using WL versus ESL (median, 73.2 vs. 52.5 cm3; p = 0.017). The margins were positive for 10 (10 %) of the 97 ESL patients and 18 (19 %) of the 97 WL patients (p = 0.17). In the ESL group, 6 (6 %) of the 97 patients had a subsequent re-excision compared with 13 (13 %) of the 97 WL patients (p = 0.15). Despite similar operative times, ESL is superior to WL, as evidenced by decreased specimen volume and excess tissue excised. Although the difference was not statistically significant, ESL resulted in fewer positive margins and re-excisions than WL. Further studies are needed to confirm that ESL is the most advantageous of the two methods.

Spotlight in Plastic Surgery: April 2023.

Spotlight in Plastic Surgery: April 2023.

A series of the first 13 combined Magseed and Magtrace cases in a single centre in regional Victoria.

The standard journey for a patient with impalpable breast cancer wishing to undergo breast-conserving surgery involves placement of a guidewire and lymphoscintigraphy pre-operatively. Access to these procedures is limited in the regional centres, this scheduling can require overnight stays away from home and can delay theatre which can increase patient distress. The Sentimag technology uses magnetism for localisation of preoperatively inserted Magseeds (for impalpable breast lesions) and Magtrace (for sentinel node biopsy), avoiding guidewire placement and nuclear medicine. This study evaluates the first 13 cases using this combined technique by a single specialist breast surgeon in a regional centre. Thirteen consecutive patients were enrolled with ethics approval. Magseeds were placed under ultrasound guidance preoperatively, and Magtrace was injected at the time of pre-operative consultation. The median age of patients was 60 (range 27-78). The average distance from hospital was 81.63 km (2.8-238 km). The average operating time was 1h54m (range 1 h 17 m-2 h 39 m) and the mean total journey time was 8h54m (range 6-23 h). The earliest time-out was 8:40 am. Re-excision rate was 23% (n= 3), however, in each re-excision case the lesions were in the axilla, were small (<15 mm) and were in patients with dense breasts on mammography. There were no significant adverse outcomes. In this preliminary study Sentimag localisation appears to be safe and reliable when used in combination. Re-excision rates were only slightly higher than reported in the literature and predicted to downtrend with ongoing learning curve.

Adequacy of surgical margins, re-excision, and evaluation of factors associated with recurrence: a retrospective study of 769 basal cell carcinomas

BackgroundAchieving adequate surgical margins and preventing recurrence are important in the treatment of basal cell carcinoma (BCC). ObjectivesThe objectives of this study were to evaluate the adequacy of surgical margins and the re-excision rates in patients with primary BCC who underwent standard surgical treatment using our proposed algorithm and to define the risk factors in patients with recurrent BCC. MethodsThe medical records of patients who were histopathologically diagnosed with BCC were reviewed. An algorithm created based on previous literature was used to determine the distribution of optimal surgical margins adequacy and re-excision rates. ResultsStatistically significant differences were observed between the cases with and without recurrence in age at diagnosis (p=0.004), tumor size (p=0.023), tumor location in the H zone of the face (p=0.005), and aggressive histopathological subtype (p=0.000). When the tumors were evaluated for adequacy of deep and lateral surgical margins and re-excision rates, higher rates of adequate excision (457 cases, 68.0%) and re-excision (43 cases, 33.9%) were noted for tumors in the H or M zone. Study limitationsInadequate follow-up of newly diagnosed patients in terms of recurrence and metastasis and the retrospective application of our proposed algorithm are the limitations of the present study. ConclusionsOur results showed that if BCC was detected at an early age and at an early stage, recurrence was lower. The H and M zones were the regions with the highest rates of optimal surgical outcomes.