Surgical Margins In Breast-conserving Surgery Research Articles

A comparative study of learning curves among general surgery residents for intraoperative ultrasound-guided breast-conserving surgery

Breast-conserving surgery (BCS) followed by radiotherapy is preferred for early-stage breast cancer because its survival rate is equivalent to that of mastectomy. Achieving negative surgical margins in BCS is crucial to minimize the risk of recurrence. Intraoperative ultrasound (IOUS) enhances surgical accuracy, but its efficacy is operator dependent. This study aimed to compare the success of achieving negative margins using IOUS between an experienced breast surgeon and general surgical residents and to evaluate the learning curve for the residents. A prospective study involving 96 patients with BCS who underwent IOUS guidance was conducted. Both the breast surgeon and residents assessed the surgical margins using IOUS, with the breast surgeon making the final margin adequacy decision. Permanent histopathological analysis was used to confirm the status of the margins and was considered the gold standard for comparison. The breast surgeon accurately assessed the margin status in all 96 cases (100% accuracy), with 93 negative and three positive margins. All of these were ductal carcinomas in situ. Initially, the residents demonstrated low accuracy rates in predicting margin positivity using intraoperative ultrasonography. However, the learning curves of the three residents demonstrated that, with an average 12th case onwards, a significant improvement in the cumulative accuracy rates was observed, which reached the level of the breast surgeon. IOUS is an effective tool for accurately predicting the margin status in BCS, with an acceptable learning curve for novice surgeons. Training and experience are pivotal for optimizing surgical outcomes. These findings support the integration of IOUS training into surgical education programs to enhance proficiency and improve patient outcomes.

Three-dimensional surgical margin positioning technique versus palpation-guided method for breast-conserving surgery: Feasibility, advantages, and quality of life

BackgroundThe accurate evaluation of surgical margins holds crucial importance in determining the success of breast-conserving surgery (BCS). The aim of this study was to introduce a novel technique for the positioning of surgical margins in BCS while highlighting its advantages. MethodsThis study included a cohort of breast cancer patients who underwent BCS. The patients were categorized into two groups: one group underwent BCS with the traditional palpation-guided method, and the other with the 3D-MPT technique. The study assessed and compared the feasibility, advantages, and outcomes in terms of quality of life between the two groups. ResultsA total of 80 patients were successfully enrolled in the study. No significant differences in clinicopathological features were observed between the two groups. The 3D-MPT technique was found to be feasible and offered several advantages over the palpation-guided method. The utilization of guide wires by experienced radiologists to position the margins before surgery enabled precise and swift specimen removal, resulting in the conservation of valuable time and a reduction in the need for re-excision. Furthermore, the 3D-MPT technique exhibited the potential to enhance cosmetic outcomes and elevate patient satisfaction, particularly in cases with uncertain tumor boundaries detectable by palpation. ConclusionThe 3D-MPT technique proves to be an effective and safe approach for reducing tumor positivity rates in initial surgical margins, thereby improving the quality of life for patients undergoing breast-conserving surgery in comparison to the conventional method.

Risk Factors for Positive Margins in Breast-Conserving Surgery.

Introduction Breast-conserving surgery (BCS) followed by adjuvant radiotherapy has similar overall survival compared to mastectomybut is associated with higher rates of local recurrence. Positive surgical margins in BCS are the most important predictor of local recurrence. The aim of our study was to assess the risk factors associated with positive margins in women undergoing BCS for breast cancerin order to inform our clinical practice and minimize re-operation rates. Methods Patients with a diagnosis ofbreast cancer who underwent BCS from January 2013 to January 2021 were identified from our pathology database and included in the study. All patients underwent a lumpectomy with the removal of additional shaved cavity margins. Statistical analysis was used toassess the effect of patient clinical and pathological risk factors on the rate of positive margins. Results One hundred and twenty patients underwent BCS for breast cancer. Twenty-four percent of patients had positive margins. Of the 29 patients that underwent subsequent re-excisions, only 13 (45%) hadresidual disease in the re-excision specimen. In younger patients, tumors localized in lower quadrants and the presence of extensive intraductal component within invasive breast cancer increased the risk of positive margins. In addition, positive margins were encountered more significantly in patients with ductal carcinoma in situ (DCIS) compared to invasive tumors. Multivariate analysis showed that DCIS and young age were the only factors independently associated with positive margins. Conclusion DCIS and younger patients have a higher rate of positive margins during BCS than invasive breast cancer. For such patients at higher risk of positive margins, excision of cavity shave margins and intraoperative inking may be done to lower positive margin rates.Preoperative review of breast imaging, core biopsies, and counseling of patients about the likelihood of positive margins is important.

Multimodal Optical Coherence Tomography for Intraoperative Evaluation of Tumor Margins and Surgical Margins in Breast-Conserving Surgery.

We compare the effectiveness of multimodal optical coherence tomography (MM OCT) in the traditional structural OCT mode and the OCT elastography (OCE) mode in addressing two clinically important tasks: (1) detecting groups of tumor cells at surgical margins during breast-сonserving surgery (BСS) in breast cancer (BC) and (2) identifying breast tumor margins. The obtained results were correlated with corresponding histological sections. The study was performed on 100 surgical margin samples (top, bottom, medial, and lateral - four samples from each patient in total) obtained from 25 patients with BC who underwent BCS (lumpectomy), and on 25 postoperative tumor samples (to determine tumor margins). With MM OCT method, we visually and numerically assessed the scattering (level and depth of OCT signal penetration) and elastic (stiffness values, or Young's modulus (kPa)) properties of the tumor and non-tumor breast tissue and the obtained values were compared with the results of postoperative histological examination. In 4 surgical margin samples (out of 100), with the OCE method we identified groups of histologically confirmed tumor cells ("positive" resection margins) at the distance of about 5 mm from the visible tumor margin. The identified zones were larger than 0.5 mm with stiffness of more than 400 kPa in all these cases. However, the structural OCT could not identify these groups of tumors and they were not distinguishable from the surrounding fibrous tissue.In the areas of tumor into non-tumor tissue transition, structural OCT images detected tumor margins only if they were adjacent to adipose tissue and did not detect them if there were adjacent to non-tumor fibrous tissue. OCE images with high stiffness values (more than 400 kPa) and high contrast showed a clear tumor margin with both adipose and fibrous tissue. The study demonstarets the potential of MM OCT, particularly its OCE mode, as a real-time method for intraoperative tumor margin and surgical margin assessment in BCS. OCE images compared to structural OCT images visualize higher contrast between different types of breast tissue (adipose tissue, fibrous stroma, hyalinized stroma, tumor cell clusters), as well as more accurate identification of the tumor border and detection of small groups of tumor cells at surgical margins. An algorithm for intraoperative MM OCT examination of the state of the resection margin is proposed in accordance with standard clinical guidelines for achieving clean surgical margins in breast cancer patients.

Comparison of “click-to-sense” assay with frozen section analysis using simulated surgical margins in breast cancer patients

PurposeWe have shown that “Click-to-sense” (CTS) assay based on the visualization of cancer cells by fluorescence probe targeted for acrolein is useful for differentiating between the malignant and benign lesions of the breast. In the present study, we aimed to apply CTS assay to the examination of the simulated surgical margins, being compared with frozen section (FS) analysis. Experimental designThe simulated surgical margin samples (n = 300) were obtained from 1 to 2 cm distant sites from the tumor margin in the mastectomy specimens of breast cancer patients, and divided into the training (n = 150) and validation (n = 150) set. The samples were subjected to CTS assay, subsequently to FS analysis and finally to permanent section (PS) analysis. ResultsDiagnostic accuracy of the CTS assay and FS analysis was evaluated in the examination of the simulated surgical margin status finally determined by the PS analysis. In the training set, sensitivity, specificity, and accuracy was 89.3%, 98.4%, and 96.7% for the CTS assay and 89.3%, 98.4%, and 96.7% for the FS analysis. In the validation set, sensitivity, specificity, and accuracy was 93.3%, 98.3%, and 97.3% for the CTS assay, and 93.3%, 99.2%, and 98.0% for the FS analysis. ConclusionsThe CTS assay is as accurate as the FS analysis in the examination of the simulated surgical margins in breast cancer patients, and it seems to have a potential to replace the FS analysis for the intra-operative examination of surgical margins in breast-conserving surgery since it is less labor-intensive and more time-saving than the FS analysis.

Low-Field NMR Relaxometry for Intraoperative Tumour Margin Assessment in Breast-Conserving Surgery.

Simple SummaryBreast cancer is the most diagnosed cancer for women, and clear surgical margins in breast-conserving surgery (BCS) are essential for preventing recurrence. In this study, the potential of fast field-cycling 1H-NMR relaxometry as a new tool for intraoperative margin assessment was evaluated. The technique allows the determination of the tissue proton relaxation rates as a function of the applied magnetic field on small tissue samples excised from surgical specimens, at the margins of tumour resection, prior to histopathological analysis. It was found that a good accuracy in margin assessment, i.e., a sensitivity of 92% and a specificity of 85%, can be achieved. The discriminating ability shown by the relaxometric assay relies mainly on the difference of fat/water content between healthy and tumour cells. The information obtained has the potential to support the surgeon in real-time margin assessment during BCS.As conserving surgery is routinely applied for the treatment of early-stage breast cancer, the need for new technology to improve intraoperative margin assessment has become increasingly important. In this study, the potential of fast field-cycling 1H-NMR relaxometry as a new diagnostic tool was evaluated. The technique allows the determination of the tissue proton relaxation rates (R1), as a function of the applied magnetic field, which are affected by the changes in the composition of the mammary gland tissue occurring during the development of neoplasia. The study involved 104 small tissue samples obtained from surgical specimens destined for histopathology. It was found that a good accuracy in margin assessment, i.e., a sensitivity of 92% and a specificity of 85%, can be achieved by using two quantifiers, namely (i) the slope of the line joining the R1 values measured at 0.02 and 1 MHz and (ii) the sum of the R1 values measured at 0.39 and 1 MHz. The method is fast, and it does not rely on the expertise of a pathologist or cytologist. The obtained results suggest that a simplified, low-cost, automated instrument might compete well with the currently available tools in margin assessment.

Lack of definitive presurgical pathological diagnosis is associated with inadequate surgical margins in breast-conserving surgery

PurposeTo determine the impact of definitive presurgical diagnosis on surgical margins in breast-conserving surgery (BCS) for primary carcinomas; clinicopathological features were also analyzed. MethodsThis retrospective study included women who underwent BCS for primary carcinomas in 2016 and 2017. Definitive presurgical diagnosis was defined as having a presurgical core needle biopsy (CNB) and not being upstaged between biopsy and surgery. Biopsy data and imaging findings including breast density were retrieved. Inadequate surgical margins (IM) were defined per latest ASCO and ASTRO guidelines. Univariable and multivariable analyses were performed. Results360 women (median age, 66) met inclusion criteria with 1 having 2 cancers. 82.5% (298/361) were invasive cancers while 17.5% (63/361) were ductal carcinoma in situ (DCIS). Most biopsies were US-guided (284/346, 82.0%), followed by mammographic (60/346, 17.3%), and MRI-guided (2/346, 0.6%). US and mammographic CNB yielded median samples of 2 and 4, respectively, with a 14G needle. 15 patients (4.2%) lacked presurgical CNB. The IM rate was 30.0%. In multivariable analysis, large invasive cancers (>20 mm), dense breasts, and DCIS were associated with IM (p = 0.029, p = 0.010, and p = 0.013, respectively). Most importantly, lack of definitive presurgical diagnosis was a risk factor for IM (OR, 2.35; 95% CI: 1.23–4.51, p = 0.010). In contrast, neither patient age (<50) nor aggressive features (e.g., LVI) were associated with IM. ConclusionLack of a definitive presurgical diagnosis was associated with a two-fold increase of IM in BCS; other risk factors were dense breasts, large invasive cancers, and DCIS.

Predictive factors associated with involved margins in breast cancer treated with neoadjuvant chemotherapy followed by breast-conserving therapy

Introduction: This study sought to identify predictive factors of involved surgical margins in breast-conserving surgery (BCS) after neoadjuvant chemotherapy (NAC) to help guide the surgical procedure. Materials and Methods: Retrospective study of patients who had BCS after NAC between January 2008 and December 2013. Outcome measure: tumor-involved margin, defined by tumor cells on ink for invasive cancer and tumor-free margin < 2 mm for DCIS. Results: Ninety-seven patients were included. The median age of patients was 46 years old [28–71]. The initial average tumor size was 47.8 mm [+/- 18.6]. Twelve patients (12.4%) had involved tumor margins on final histology after BCS and NAC. According to the multivariate model including only preoperative variables of positive margins, initial ultrasound tumor size ≤ 27 mm (p = 0.045) and low SBR grade (p = 0.009) were independently associated with tumor-involved margins. According to the multivariate model including pre- and postoperative variables of positive margins, ductal carcinomain situ was also independently associated with tumor-involved margins (p = 0.021). Conclusion: Initial ultrasound tumor size ≤ 27 mm and low SBR grade were independently associated with tumor-involved margins. These preoperative data were very helpful to guide the surgical procedure in breast cancer.

Effect of LigaSure™, Monopolar Cautery, and Bipolar Cautery on Surgical Margins in Breast-Conserving Surgery

Background: We compared the differences in thermal damage at the surgical margin between monopolar cautery, bipolar cautery, and LigaSure™ in breast cancer lumpectomy specimens and assessed the effect of these techniques on the evaluation of the surgical margins. Methods: 30 patients scheduled for breast-conserving surgery for breast cancer were included in this study. During lumpectomy, each of the superior, inferior, lateral, and medial borders of the tumour was excised using one of the following: a scalpel, monopolar cautery, bipolar cautery, and LigaSure technology. The surgical margins of frozen and paraffin-embedded tissue sections of the lumpectomy specimen were evaluated. Thermal damage was defined as the maximum depth of thermal damage (in mm) from the surgical margin, and the level was categorized as none, low (≤1 mm), or high (>1 mm). Results: There was no statistically significant difference between monopolar cautery, bipolar cautery, and LigaSure in terms of thermal damage. There was no thermal damage at the surgical margin in tissues dissected by scalpel. Conclusion: Thermal damage due to the excision method may cause false-negative and false-positive results in the surgical margin evaluation of lumpectomy specimens. More research is needed on the effects of different energy modalities on surgical margin evaluation in breast-conserving surgery.

Predictors of Positive or Close Surgical Margins in Breast-Conserving Surgery for Patients with Breast Cancer

Predictors of Positive or Close Surgical Margins in Breast-Conserving Surgery for Patients with Breast Cancer

Risk factors for positive resection margins of breast cancer tumorectomy specimen following breast-conserving surgery.

Background The aim of the study was to identify risk factors for positive surgical margins in breast-conserving surgery for breast cancer and to evaluate the influence of surgical experience in obtaining complete resection. Methods All lumpectomies for invasive breast carcinoma and ductal carcinoma in situ (DCIS) between April 2008 and March 2010 were selected from the database of a single institution. Re-excision rates for positive margins as well as patient and histopathologic tumor characteristics were analyzed. Surgical experience was staged by pairs made of Resident plus Specialist or Consultant. Two periods were defined. During period A, the majority of operations were performed by Residents under supervision of Specialist or Consultant. During period B, only palpable tumors were operated by Residents. Results The global re-excision rate was 27% (50 of 183 patients). The presence of DCIS increased the risk for positive margins: 60% (nine of 15 patients) in the case of sole DCIS compared to 26% (41 of 160 patients) for invasive cancer (p = 0.005) and 35% (42 of 120 patients) in the case of peritumoral DCIS compared to 11% (seven of 62 patients) in the case of sole invasive cancer (p = 0.001). Re-excision rate decreased from 36% (23 of 64 patients) during period A to 23% (27 of 119 patients) during period B (p = 0.055). There was no significant difference between the surgical pairs. Conclusion In our study, DCIS was the only risk factor for positive surgical margins. Breast-conserving surgery for non-palpable tumors should be performed by Specialists, however, palpable tumors can be safely operated by Residents under supervision.

Optimizing Surgical Margins in Breast Conservation

Adequate surgical margins in breast-conserving surgery for breast cancer have traditionally been viewed as a predictor of local recurrence rates. There is still no consensus on what constitutes an adequate surgical margin, however it is clear that there is a trade-off between widely clear margins and acceptable cosmesis. Preoperative approaches to plan extent of resection with appropriate margins (in the setting of surgery first as well as after neoadjuvant chemotherapy,) include mammography, US, and MRI. Improvements have been made in preoperative lesion localization strategies for surgery, as well as intraoperative specimen assessment, in order to ensure complete removal of imaging findings and facilitate margin clearance. Intraoperative strategies to accurately assess tumor and cavity margins include cavity shave techniques, as well as novel technologies for margin probes. Ablative techniques, including radiofrequency ablation as well as intraoperative radiation, may be used to extend tumor-free margins without resecting additional tissue. Oncoplastic techniques allow for wider resections while maintaining cosmesis and have acceptable local recurrence rates, however often involve surgery on the contralateral breast. As systemic therapy for breast cancer continues to improve, it is unclear what the importance of surgical margins on local control rates will be in the future.

Computer-assisted complete three-dimensional reconstruction of the mammary ductal/lobular systems: implications of ductal anastomoses for breast-conserving surgery.

The intraductal spread of breast carcinoma can occur along the mammary ductal/lobular systems (MDLS) with no invasion of tissues. Because ductal anastomoses in the MDLS are considered to be a possible risk factor for extensive intraductal spread of breast carcinoma, the architecture of the MDLS has important therapeutic implications for patients treated with breast-conserving surgery. An entire breast resected by subcutaneous mastectomy from a 69-year-old woman with ductal carcinoma in situ (DCIS) was examined in submacroscopic sections by stereomicroscopic and histologic techniques. Serial 2-mm sections underwent computer-assisted complete three-dimensional reconstruction of all MDLS. The entire breast that was studied contained 16 MDLS that were arranged radially, with the nipple at the center. Of these 16 MDLS, 4 (25.0%) had ductal anastomoses whereas the remaining 12 MDLS had no ductal anastomoses and completely independent regional anatomy. Ductal anastomoses were observed at 11 sites in the 4 MDLS. The 2 of 11 ductal anastomoses that connected different MDLS (18.2%) were situated > 4 cm from the nipple. The remaining nine ductal anastomoses connected ducts within the same MDLS; their location varied from near the nipple to the peripheral region. In the specimen examined, DCIS extended only within a single MDLS and did not spread between different MDLS via ductal anastomoses. To the authors' knowledge, the current study is the first time the complete architecture of all MDLS in an entire breast has been studied three-dimensionally. The risk of promoting the intraductal spread of disease during surgery may be greater when intraductal lesions extend more peripherally than centrally. The features of ductal anastomoses may provide a significant anatomic clue regarding negative surgical margins in breast-conserving surgery.