Shave Margins Research Articles

Abstract PD3-02: Intraoperative tumor detection using a ratiometric activatable fluorescent peptide: A first-in-human phase I study allows tumors to be visualized in the operating room

Abstract Background: A continuing challenge in breast cancer surgery is the difficulty with intraoperative lymph node status determination and achieving negative surgical margins. Current techniques such as frozen section, touch prep and intraoperative radiographic imaging are time consuming and vary in accuracy from institution to institution. Our study is a first-in-human study of a novel ratiometric activatable cell penetrating fluorescent peptide dye conjugate that labels breast cancer tumor tissue in vivo. Methods: AVB-620 is a substrate for and activated by proteases in the matrix metalloproteinase family. It has two fluorophores moieties linked by a cleavable peptide. Upon cleavage, there is an increase in fluorescence intensity and a change in the predominant wavelength of fluorescence emission. AVB-620 was given preoperatively via intravenous infusion to stage 0-III breast cancer patients. Patients were monitored for safety and AVB-620 pharmacokinetic parameters determined. After 12-20 hours, patients underwent lumpectomy or mastectomy with either sentinel lymph node biopsy (SLNB) or axillary lymph nodes dissection (ALND). Using a customized near-infrared camera system, fluorescence intensity signals at two wavelengths were measured intraoperatively both in vivo and ex vivo of primary tumors, shave margins and lymph nodes. The intensity ratio of these two wavelengths was utilized to distinguish between malignant and non-malignant tissues. Images were correlated to pathology reports. Results: Fifteen patients with average age of 59 years were enrolled across 5 dose cohorts without any significant adverse events. All patients underwent definitive breast surgery (12 lumpectomy, 3 mastectomy) and axillary surgery (12 – SLNB, 3- ALND). Four patients that had tumor-positive lymph nodes confirmed pathologically which correlated with increased fluorescence intensity and ratio on imaging. Primary tumor images also demonstrated fluorescence intensity and ratiometric changes that distinguished cancerous and non-cancerous tissues. Discussion: The purpose of this phase 1 dose escalation was to determine safety profile and adequate dosing. This study demonstrated a proof of concept of the use of a protease-activatable ratiometric fluorescent peptide dye conjugate to identify malignant tissue intraoperatively. Increased fluorescent ratio correlated and resulted in fluorescent imaging of known tumor in the operating room, with images that directly correlated with position of tumor in the excised tissue. This approach has the potential to quickly and accurately visualize the pathologic status of tumor margins and lymph node intraoperatively. Further studies to optimize dose, timing of administration, and thresholds for ratiometric imaging are underway. Citation Format: Unkart JT, Chen SL, González JE, Harootunian A, Wallace AM. Intraoperative tumor detection using a ratiometric activatable fluorescent peptide: A first-in-human phase I study allows tumors to be visualized in the operating room [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 PD3-02.

Cavity Shaving Reduces Involved Margins and Reinterventions Without Increasing Costs in Breast-Conserving Surgery: A Propensity Score-Matched Study.

Currently, reinterventions for involved margins after breast-conserving surgery remain common. The aim of this study was to assess the capability of the cavity shave margins (CSM) technique to reduce positive margin rates and reoperations compared with simple lumpectomy (SL). The impact of CSM on the various biological portraits of breast cancer and costs were also investigated. A retrospective review of 976 consecutive patients from a single center was performed; 164 patients underwent SL and 812 received CSM. All patients were treated with an oncoplastic approach.and involved margins and reoperations were compared for each group. To avoid selection bias, propensity score-matched analysis was performed before applying a logistic regression model. Main outcomes were reanalyzed for each biological portrait, and surgery and hospitalization costs for SL and CSM were compared. Clear margins were found in 98.3% of patients in the CSM group versus 74.4% of patients in the SL group (p<0.001). The reoperation rate was 18.9% in the SL group and 1.9% in the CSM group (p<0.001). After propensity score-matched logistic regression, odds ratio (OR) for positive final margin status was 6.2 (95% confidence interval [CI] 2.85-13.46; p<0.001) without CSM, while OR for reintervention was 5.46 (95% CI 2.21-13.46; p<0.001). CSM significantly reduced positive margins and reexcisions for Luminal A, Luminal B, and triple-negative breast cancers (p<0.001, p<0.001, and p=0.0137, respectively). SL had higher global costs compared with CSM: €193,630.6 versus €177,830 for 100 treated patients (p=0.009). CSM reduces reexcisions, mainly in luminal breast cancers, without increasing costs.

Should cavity shave margins be performed as a routine in breast conserving surgery? A review of randomised controlled trials

Background Breast conserving surgery (BCS) is the standard of care for women with early breast cancer. The margin status is crucial in breast conserving surgery and is an important determinant for local recurrence. Local recurrence is associated with decreased overall and disease-free survival. Several studies have shown that cavity shave margin reduces the rate of positive margins and local recurrence. This review analyses the randomised controlled trials to compare the role of cavity shave margin in breast conserving surgery and its effect on positive margins and re-excision rates. Methods A systematic search of literature published before December 2016 for randomised controlled trials in MEDLINE, Pubmed, EMBASE, Proquest, Cochrane central register of controlled trials and Google scholar was peformed. Out of 12 articles 2 randomised controlled trials were eligible. Positive margins and re-excision rates were analysed using odds ratio and risk difference. Results Out of 12 studies, 2 were suitable for review. Overall positive margins were 18.3% and 36% in the CSM and No-CSM groups respectively, with an odds ratio of 0.373 (95% CI, 0.189 to 0.739, P = 0.232) and risk difference of -0.194 (95% CI, -0.336 to -0.053, P= 0.198). The re-excision rates were lower in the CSM group when compared to the No-CSM group (12.2% vs 31.3%) with an odds ratio of 0.28 (95% CI, 0.160 to 0.520, P=0.578) and risk difference was -0.199 (95% CI, -0.309 to -0.089, P=0.264). Conclusion Analysis of the randomised controlled trials showed that cavity shave margins significantly reduced the risk of positive margins and the need for re-excision. It is a beneficial technique in women undergoing lumpectomy and breast conserving surgery. Keywords: Early breast cancer, breast conserving surgery, cavity shave margins.

Abstract P3-13-01: Impact of routine cavity shave margins on time and money: Results from the SHAVE trial

Abstract INTRODUCTION: Taking routine cavity shave margins (CSM) reduces positive margin and re-excision rates by 50%, but the impact of this technique on operative time and overall costs have not been well-elucidated. METHODS: The SHAVE trial randomized 235 Stage 0-3 breast cancer patients undergoing partial mastectomy 1:1 to either have further cavity shave margins resected ("shave") or not ("no shave"). Randomization occurred intraoperatively after surgeons had completed standard partial mastectomy. Intraoperative time as well as actual direct costs incurred by the hospital were measured, for both the index case as well as any surgeries over the subsequent 90 days. RESULTS: Median patient age was 61 (range; 33-94). 54 patients (23%) had invasive cancer, 45 (19%) had DCIS, and 125 (53%) had both. Median invasive tumor size was 1.1 cm (range; 0-6.5), and median DCIS size was 1.0 cm (range; 0-9.3). The "shave" and "no shave" groups were well-matched in terms of baseline characteristics, including the proportion having a sentinel node biopsy (75.6% vs. 69.8%, p=0.32) and/or axillary node dissection (9.2% vs. 7.8%, p=0.68) at the time of the initial surgery. The median number of additional CSM in the "shave" group was 4 (range; 3-6). At the initial surgery, those in the "shave" group had a longer operative time (median 76 vs. 66 minutes, p=0.005), and higher OR, pathology and total costs (see table). 48 patients required a subsequent surgery; 45 (93.8%) for margin clearance, 3 for sentinel lymph node biopsy alone (2 in the "shave" and 1 in the "no shave" group, p=1.00). There was a significantly lower re-excision rate for margins in the "shave" group (10.9% vs. 27.6%, p=0.001). Median time to re-excision was 22 days (range; 10-62). The mean cost of additional surgeries for those who required them was no different between the "shave" and "no shave" groups ($2636 vs. $3453, p=0.12); however, given the overall lower reoperation rate in the "shave" group (12.6% vs. 28.4%, p=0.003), the mean cost per patient for additional surgeries was significantly lower in the "shave" vs. "no shave" group. Taking into account all surgeries (including the index case and any additional surgeries within 90 days), there was no significant difference in cost (from a hospital perspective) between the two groups. Mean (± SE) Costs per patient"Shave" (n=119)"No Shave" (n=116)p-valueIndex surgery: OR costs$1315 (± $69)$1138 (± $52)0.042Pathology costs$1195 (± $43)$795 (± $48)&amp;lt; 0.001Total costs$4758 (± $123)$4133 (± $119)&amp;lt; 0.001Additional surgery: OR costs$94 (± $24)$247 (± $44)0.003Pathology costs$51 (± $18)$112 (± $21)0.031Total costs$332 (± $88)$983 (± $189)0.002Total 90 day surgery costs: OR costs$1409 (± $76)$1385 (± $64)0.808Pathology costs$1247 (± $49)$909 (± $52)&amp;lt; 0.001Total costs$5090 (± $166)$5116 (± $214)0.925 CONCLUSIONS: Taking routine CSM is associated with increased time and cost for the index surgery, but this is offset by the cost savings of reduced re-excision rates. While the strategies of "shave" and "no shave" are similar in terms of 90 day hospital-related costs, taking CSM is associated with a lower need for reoperative surgery, thereby reducing patient angst and improving utilization of surgeon and OR time. Citation Format: Chagpar AB, Longley PB, Horowitz NR, Killelea BK, Tsangaris TN, Li F, Butler M, Stavris K, Yao X, Harigopal M, Bossuyt V, Lannin DR, Pusztai L, Loftus M, Davidoff AJ, Gross CP. Impact of routine cavity shave margins on time and money: Results from the SHAVE trial. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-13-01.

Recurrence of Dysplastic Nevi Is Strongly Associated with Extension of the Lesions to the Lateral Margins and into the Deep Margins through the Hair Follicles in the Original Shave Removal Specimens.

Melanocytic nevi, including dysplastic or atypical nevi (DN), can recur or persist following shave removal procedures, and recurrence may resemble melanoma, both clinically and histologically (pseudomelanoma). Recurrence may originate from proliferation of the remaining neoplastic melanocytes following incomplete removal. The present study determines the rate and etiology of this event. A cross-sectional analysis of 110 excision specimens showing histological recurrence was performed, and these specimens were compared to the slides of the original shave specimens showing mildly atypical DN. In the second portion of the study, a retrospective review of 167 cases with biopsy-proven mildly atypical DN which were followed up for at least two years was conducted to determine the rate of recurrence/persistence. When followed up for two years, DN, with positive shave margins, defined by extension or very close extension (≤0.2 mm) of the lesions to the lateral margins and into the deep margins through the hair follicles in the shave removal specimens, have a higher probability of recurrence than DN with negative (or clear) margins (odds ratio (OR) = 158; 95% confidence interval (CI) = 36.62–683; P < 0.001). The overall rate of histologically confirmed recurrence/persistence was approximately 10%.

Ultrasound-Guided Versus Wire-Guided Breast-Conserving Surgery for Nonpalpable Breast Cancer

PurposeTo determine the efficacy of ultrasound (US)-guided excision of nonpalpable breast cancer and compare it to standard wire-guided breast-conserving surgery (BCS). MethodsOne hundred fifty-eight women with nonpalpable breast cancer who underwent BCS were retrospectively studied. Positive surgical margins and reexcision rates were investigated. ResultsOf the total cohort, 68 patients were treated with wire-guided and 90 with US-guided tumor excision. The tumor and patient characteristics were similar in the 2 groups; 13.2% and 12.2% of patients in the wire-guided and US-guided groups, respectively, had positive margins. Patient age, menopausal status, tumor size, histologic type, and histologic grade were associated with increased risk of positive margins. The shave margins were reexcised at the time of original operation more often by wire-guided localization (26.5%) than in the US-guided group (10.0%) (P = .010). The surgeon was able to identify correctly the problematic margin in 100% via intraoperative US and in only 27.8% when the wire-guided surgery was used (P < .001). The reexcision rate by a second operation was similar in 2 groups (P = .798). Eight (11.8%) of 68 patients in the wire-guided group and 9 (10.0%) of 90 patients in the US-guided underwent a second operation. ConclusionUS-guided BCS is as effective and safe as standard wire-guided excision of nonpalpable breast tumors.

A Randomized, Controlled Trial of Cavity Shave Margins in Breast Cancer

BackgroundRoutine resection of cavity shave margins (additional tissue circumferentially around the cavity left by partial mastectomy) may reduce the rates of positive margins (margins positive for tumor) and reexcision among patients undergoing partial mastectomy for breast cancer.MethodsIn this randomized, controlled trial, we assigned, in a 1:1 ratio, 235 patients with breast cancer of stage 0 to III who were undergoing partial mastectomy, with or without resection of selective margins, to have further cavity shave margins resected (shave group) or not to have further cavity shave margins resected (no-shave group). Randomization occurred intraoperatively after surgeons had completed standard partial mastectomy. Positive margins were defined as tumor touching the edge of the specimen that was removed in the case of invasive cancer and tumor that was within 1 mm of the edge of the specimen removed in the case of ductal carcinoma in situ. The rate of positive margins was the primary outcome measure; secondary outcome measures included cosmesis and the volume of tissue resected.ResultsThe median age of the patients was 61 years (range, 33 to 94). On final pathological testing, 54 patients (23%) had invasive cancer, 45 (19%) had ductal carcinoma in situ, and 125 (53%) had both; 11 patients had no further disease. The median size of the tumor in the greatest diameter was 1.1 cm (range, 0 to 6.5) in patients with invasive carcinoma and 1.0 cm (range, 0 to 9.3) in patients with ductal carcinoma in situ. Groups were well matched at baseline with respect to demographic and clinicopathological characteristics. The rate of positive margins after partial mastectomy (before randomization) was similar in the shave group and the no-shave group (36% and 34%, respectively; P=0.69). After randomization, patients in the shave group had a significantly lower rate of positive margins than did those in the no-shave group (19% vs. 34%, P=0.01), as well as a lower rate of second surgery for margin clearance (10% vs. 21%, P=0.02). There was no significant difference in complications between the two groups.ConclusionsCavity shaving halved the rates of positive margins and reexcision among patients with partial mastectomy. (Funded by the Yale Cancer Center; ClinicalTrials.gov number, NCT01452399.)

Intraoperative Assessment of Final Margins with a Handheld Optical Imaging Probe During Breast-Conserving Surgery May Reduce the Reoperation Rate: Results of a Multicenter Study.

A multicenter, prospective, blinded study was performed to test the feasibility of using a handheld optical imaging probe for the intraoperative assessment of final surgical margins during breast-conserving surgery (BCS) and to determine the potential impact on patient outcomes. Forty-six patients with early-stage breast cancer (one with bilateral disease) undergoing BCS at two study sites, the Johns Hopkins Hospital and Anne Arundel Medical Center, were enrolled in this study. During BCS, cavity-shaved margins were obtained and the final margins were examined ex vivo in the operating room with a probe incorporating optical coherence tomography (OCT) hardware and interferometric synthetic aperture microscopy (ISAM) image processing. Images were interpreted after BCS by three physicians blinded to final pathology-reported margin status. Individual and combined interpretations were assessed. Results were compared to conventional postoperative histopathology. A total of 2,191 images were collected and interpreted from 229 shave margin specimens. Of the eight patients (17 %) with positive margins (0 mm), which included invasive and in situ diseases, the device identified all positive margins in five (63%) of them; reoperation could potentially have been avoided in these patients. Among patients with pathologically negative margins (>0 mm), an estimated mean additional tissue volume of 10.7 ml (approximately 1% of overall breast volume) would have been unnecessarily removed due to false positives. Intraoperative optical imaging of specimen margins with a handheld probe potentially eliminates the majority of reoperations.

Can routine cavity shave margins (CSM) improve local control in breast cancer? Initial results of the SHAVE trial, a prospective randomized controlled trial of routine CSM vs. standard partial mastectomy (SPM).

1012 Background: Considerable controversy exists regarding the utility of routine CSM in patients undergoing partial mastectomy for breast cancer. We performed a prospective RCT to determine whethe...

The CUBE technique: continuous ultrasound-guided breast excision.

Margin negativity is a critical endpoint in breast-conserving surgery. Despite advances in technology, there is up to a 40 % positive margin rate in lumpectomy specimens, which results in a twofold increase in ipsilateral breast tumor recurrence. We have developed a new method for lumpectomy that could improve margin negativity. A novel method for partial mastectomy was developed using ultrasound to perform dissection of breast specimens in real time. Continuous ultrasound-guided breast excision (CUBE) was first tested on gel models and subsequently implemented in vivo. The step-by-step method for this technique was performed on 12 successive patients who had ultrasound-detectable lesions. Twelve patients underwent lumpectomy for cancer using the CUBE technique. All patients had negative margins on final pathology. Three patients who had close margins on ex vivo ultrasound evaluation had additional shave margins taken, resulting in negative final margins. The CUBE technique is a novel technique that allows for dissection of breast lesions with continuous visualization of margins. This facilitates real-time adjustments to ensure margin negativity. Preliminary data is promising, but further research is needed for confirmation.

Margins: a status report from the Annual Meeting of the American Society of Breast Surgeons.

Since the emergence of breast conserving surgery (BCS) as an alternative to mastectomy in the 1980's, there has been little consensus on what constitutes acceptable margins for cases of invasive breast cancer, how best to evaluate margins in the operating room, or an understanding of the challenging process of margin assessment by pathologists. The program committee for the 15th Annual Meeting of The American Society of Breast Surgeons organized a plenary session to discuss the latest thinking and guidelines for these important issues. The SSO/ASTRO Consensus Guideline on Margins for BCS was an important focus of discussion. The SSO/ASTRO consensus panelists concluded that "no ink on tumor" is an adequate surgical margin for BCS in patients with invasive breast cancers. Intraoperative strategies to decrease the incidence of positive margins include intraoperative localization techniques (wire-localization, ultrasound, radioactive seed) and intraoperative margin assessments with specimen radiography, imprint cytology, and frozen section. Studies also demonstrate the positive effect of shave margins with or without intraoperative margin assessment. The College of American Pathologists protocols for breast specimen margin evaluation consider multiple variables that can impact the proper assessment of margins. These variables include: tissue fixation time, specimen orientation, cold ischemia time, leaking ink, specimen pancaking and others that surgeons need to be aware of. Determining when "enough is enough" should not only be the application of guidelines and national standards, but also a multidisciplinary discussion between breast cancer specialists for what is right for the individual patient's unique circumstances.

Ultrasonography-Guided Breast-Conserving Surgery Is Superior to Palpation-Guided Surgery for Palpable Breast Cancer

IntroductionThe aim of this study was to determine the efficacy of ultrasonography (US)–guided excision of palpable breast cancer and to compare it with the standard palpation-guided breast-conserving surgery (BCS). MethodsFor this purpose, 335 women with palpable breast cancer who underwent BCS were retrospectively studied. The positive surgical margins and re-excision rates were investigated. ResultsOf the total cohort, 137 patients were treated with palpation-guided BCS and 198 underwent US-guided tumor excision. The tumor and patient characteristics were similar in both groups. Patient age, postmenopausal status, tumor size, histological grade, intraductal tumor component, lobular histology, and palpation-guided tumor excision were associated with increased risk of positive margins. The shave margins were re-excised at the time of original operation more often by palpation-guided localization (28.5%) than by the US-guided procedure (11.1%) (P < .0001). A surgeon was able to correctly identify the “problematic” margin in 81.1% of cases via intraoperative US and in only 17.9% via palpation (P < .0001). The re-excision rate during a second operation was significantly reduced by US-guided tumorectomy (P = .004). Of 198 patients in the US-guided group, 23 (11.6%) underwent a second operation, as did 33 of 137 patients in the palpation group (24.1%). The sensitivity and specificity of US-guided excisions were 52.7% and 97.5%, respectively, whereas the sensitivity and the specificity of palpation-guided tumor excisions were 15.5% and 65.9%, respectively. ConclusionUS-guided BCS is superior to palpation-guided excision in predicting the closest margins, obtaining clear surgical margins, and reducing re-operations.

SHAVE: A randomized controlled trial of routine shave margins versus standard partial mastectomy.

TPS1145 Background: It is well known that partial mastectomy for breast cancer is associated with a positive margin rate of 20-40% in most series. This has led some surgeons to advocate for routine cavity shave margins as a means of reducing re-excision rates. Others, however, feel that such a practice may be unwarranted and question the volume of tissue removed, cosmetic outcome and increase in operative time. It is unclear which of these two approaches is optimal; therefore, a prospective randomized controlled trial was proposed. Methods: Given the primary endpoint of positive margin rates (defined as a margin of &lt; 1mm), the study was powered to find a difference between 30% in the standard partial mastectomy group and 15% in the routine shave margin group. To reach a power of 80% with alpha of 5%, 122 patients were required in each arm; we therefore set N=250 with a 1:1 randomization scheme. Patients are evaluated preoperatively and all patients undergoing a partial mastectomy for stage 0-III breast cancer are eligible; including those who have completed neoadjuvant chemotherapy. Patients are stratified according to stage and randomized within strata. After informed consent, patients undergo a standard partial mastectomy (including specimen radiography as needed). Surgeons may resect additional tissue at that time according to their standard practice. At the completion of this procedure, the randomization envelope is opened in the operating room and surgeons are instructed to either shave (ie., take additional circumferential margins) or close (no shave). Patients will be followed for five years. Outcome measures include: positive margin/re-excision rate, local recurrence, volume of tissue resected, cosmetic outcome, and intraoperative time. To date, over 130 patients have accrued to this trial. Initial results are expected to be reported in 2014. Clinicaltrials.gov identifier: NCT01452399

A comparison of intra-operative margin management techniques in breast-conserving surgery: a standardised approach reduces the likelihood of residual disease without increasing operative time

Breast-conserving surgery (BCS) is established as a standard treatment option for women with early-stage invasive breast cancers. Margin status predicts local disease recurrence. Up to 59% of patients may undergo re-excision of their tumour cavity to establish clear margins. Intra-operative margin assessment may decrease re-excision rates. It is unclear if this procedure increases operative time. We compared intra-operative macroscopic assessment of margins, routine cavity shave margins and no formal intra-operative margin assessment to assess their impact on re-excision rates, residual disease burden and operative time. Over a 42month period, 188 patients from our retrospective breast cancer database were reviewed in our study. Of these, 68 had macroscopic margin assessment, 70 had cavity shave margins and 50 had no formal intra-operative assessment. Statistical analysis was performed as appropriate. Formal intra-operative margin assessment had a re-excision rate of 25%, compared with 34% for those without formal assessment. Formal assessment had a significantly reduced likelihood of having residual disease following the primary procedure (p=0.02). Close margins (<2mm) also predicted the presence of residual disease (p=0.01). There was no difference in operative duration between the groups. Directed intra-operative margin assessment reduces residual disease burden in BCS without increasing operative duration.

Is there any difference in the rate of re excision after cavity shave margins in breast conserving surgery?

Introduction: Re excision rates following breast conserving surgery have been reported around 12% to 30%, whether cavity shave margin reduces the rate of re excision remains unclear. We aim to determine whether cavity shave margins reduce the rate of re excision.

Predictors of residual disease after breast-conserving surgery.

168 Background: Locoregional failure after breast conserving surgery (BCS) is often due to undetected residual disease, and the risk of such residual disease frequently guides management. We sought to determine clinical and pathologic factors correlating with the finding of residual invasive cancer and/or DCIS in patients undergoing BCS. Methods: We performed a retrospective cohort study for all invasive and in situ breast cancer treated with BCS at a single institution in 2009. The main outcome variable of interest was residual disease determined by pathologic examinations of cavity shave margins or reexcision. Chart review and statistical analyses were performed to evaluate clinical and pathological factors correlating with residual DCIS or invasive cancer. Results: 256 in situ or invasive breast cancers were treated with BCS in 2009. Of these, 207 (80.9%) underwent additional resection either for close margins or as routine practice. These formed the cohort of interest for this study. 39 patients (18.8%) had residual DCIS and 22 (10.6%) had residual invasive disease. Age, race, histology, ER, PR, her-2-neu and margin distance for invasive disease did not predict the finding of residual DCIS nor invasive cancer. Lymphovascular invasion, while not predicting residual DCIS, was correlated with the finding of residual invasive disease (28.0% vs. 7.9%, p=0.007). Margin distance for DCIS was not predictive of residual invasive cancer but was predictive of residual DCIS. 33.8% of lesions with DCIS margins &lt;1mm were associated with residual DCIS, while 3.4% of those with DCIS margins &gt;5mm were associated with residual in situ disease (p=0.002). Increasing tumor size for invasive and in situ disease were associated with residual DCIS (median 19.5 vs. 13.0 mm, p=0.001 and 22.5 vs. 15.0 mm, p&lt;0.001, respectively); however, neither size component was associated with residual invasive disease. Conclusions: While margin distance and tumor size are associated with residual DCIS in patients undergoing BCS, these are not correlated with residual invasive disease. Conversely, the finding of lymphovascular invasion predicts residual invasive cancer, but not DCIS. These factors may aid in risk stratification of patients and guide postoperative management.

An audit of detailed margin assessment in breast conserving surgery specimens supports the routine use of shaved radial margins

Aim The status of excision margins is a well recognised predictive factor for likelihood of recurrence following breast conserving surgery (BCS). Radial margins may be examined by perpendicular sections or shaving. The aim of this audit was to determine what, if any, additional information shave margins provide. Methods Three hundred consecutive BCS specimens were reviewed, with shave margins having been performed in 209. Histological involvement of radial and shave margins for invasive carcinoma, ductal carcinoma in situ and pleomorphic lobular carcinoma in situ was recorded, as were findings in any further re-excision specimens. Results In 13% of cases shave margins only were positive, and 57% of these cases had residual invasive or in situ disease in re-excision specimens. In 8% of cases where both the radial and shave margins were involved, the positive shave margin was different to the radial and would have led to a more extensive re-excision. Therefore shave margins gave additional information to clinicians and impacted on surgical management in 21% of cases. Conclusions Shave margins from BCS specimens appear to identify margin involvement in an increased proportion of patients who would otherwise be left with residual disease. We suggest that these findings support the routine use of shave margins despite current Royal College of Pathologists of Australasia (RCPA) recommendations.

Influence of Surgical Technique on Mastectomy and Reexcision Rates in Breast-Conserving Therapy for Cancer

Introduction. Breast conserving surgery (BCS) requires tumor excision with negative margins. Reexcision rates of 30–50% are reported. Ultrasound localization, intraoperative margin pathology, and specimen mammography have reduced reexcisions, but require new equipment. Cavity shave margin (CSM) is a technique, utilizing existing equipment, that potentially reduces reexcision. This study evaluates CSM reexcision impact. Methods. 522 cancers treated with BCS were reviewed. Patients underwent standard partial mastectomy (SPM) or CSM. Data collected included demographics, pathology, and treatments. Results. 455 SPMs were compared to 67 CSMs. Analysis revealed no differences in pathology, intraductal component, or neoadjuvant chemotherapy. Overall reexcision rate = 43%. Most reexcisions were performed for DCIS at margin. SPMs underwent 213 reexcisions (46.8%), versus 16/67 (23.9%) CSMs (P = 0.0003). Total mastectomy as definitive procedure was performed after more SPMs (P = 0.009). Multivariate analysis revealed CSM, % DCIS, tumor size, and race to influence reexcisions. Conclusions. CSM is a technique that reduces reexcisions and mastectomy rates.

Ultrasound-Guided Lumpectomy for Palpable Breast Cancers

We sought to determine the re-excision rate following lumpectomy for palpable breast cancers using intraoperative ultrasound (US). A secondary aim was to investigate the impact on surgical decision-making. We identified 73 women who underwent US-guided lumpectomy for palpable breast cancer between 2006 and 2010. A cohort of 124 women who underwent palpation-guided lumpectomy was used for a comparison group. Data included patient demographics, tumor characteristics, intraoperative findings, and pathologic outcomes. Descriptive statistics were used for data summary and compared by chi-square or t test, as appropriate. A total of 73 women underwent US-guided lumpectomy, and 124 women underwent palpation-guided lumpectomy (median age 55 years). Patients undergoing palpation-guided lumpectomy had smaller tumors that were more likely to be HER2/neu amplified compared with patients undergoing US-guided lumpectomy (P < 0.05 for each). There were no differences between the 2 groups with respect to patient age, tumor grade, and estrogen/progesterone receptor status (P > 0.05 for each). Re-excision rates were similar in both groups [17 (23%) in the US group versus 31 (25%) in the palpation group; P > 0.05]. In the US group, 45 patients (62%) had additional shave margins taken based on US interrogation of the specimen, and 12 patients (16%) were spared a 2nd procedure based on the use of intraoperative US. Although palpable breast cancers can be excised based on direct palpation or needle localization, we believe that US guidance provides an excellent tool to aid the breast surgeon. Only 10% of patients had a positive margin on final pathology as a result, and the overall re-excision rate was acceptable.

Volume of Excision and Cosmesis with Routine Cavity Shave Margins Technique

Cavity shave margin (CSM) removal is a surgical technique that reduces re-excision rates. One criticism of this technique has been that negative margins are obtained primarily as a result of higher volumes of tissue removed. This study evaluates the volume of tissue removed in a group that underwent CSM versus one that underwent standard partial mastectomy (SPM) and explores cosmetic outcomes. Single-institution retrospective review identified 533 patients with a diagnosis of breast cancer who underwent PM. Matched pair analysis of 72 patients who had undergone PM with CSM versus 72 who had undergone SPM was performed. Volumes were calculated from dimensions in the pathology report. A subgroup was analyzed by a multidisciplinary panel for cosmetic outcome using the Harvard Breast Cosmesis Grading Scale. Mean tumor size in the CSM group was 1.52 versus 1.51 cm(3) in the SPM (P = 0.8073). Mean total volume of tissue excised with CSM was lower than that in the SPM group. Mean volume of excision with CSM was 80.66 and 165.1 cm(3) in the SPM group (P = 0.0005). Patients undergoing CSM required fewer re-excisions than the SPM group: 13 (18.1%) versus 25 (34.6%) (P = 0.03). Mean score for cosmesis was 2.3 in the CSM group and 3.0 for SPM (P = 0.0004). CSM decreases the need for re-excision. Total tissue volume excised is lower in patients who undergo CSM, and cosmetic results appear to be improved. This approach should be considered for all patients undergoing PM.