Margin assessment before intraoperative radiotherapy during breast conserving surgery—Does the addition of MarginProbe decrease the need for addition of fractionated whole breast radiation?

When performing Breast Conserving Surgery (BCS) with Intraoperative Radiation Therapy (IORT), positive resection margin necessitates not only re‐lumpectomy—but also the addition of fractionated whole breast radiation. This retrospective study of 106 patients undergoing BCS and IORT aims to evaluate intraoperative margin assessment use in our center, and the contribution of the MarginProbe device (MP) to achieving negative surgical margins. Eleven out of 106 lumpectomy specimens had a total of 17 margins positive for tumor cells. Intraoperative gross pathology identified 6 (43%) involved margins, MarginProbe detected 8 (50%), and their combined use allowed for detection of 12 (70.5%) involved margins. In conclusion, the adjunctive use of intraoperative gross pathology and MarginProbe reduced the number of lumpectomies with positive resection margins by more than 50%, decreasing the need for re‐lumpectomy and the addition of whole breast radiation.     

Understanding the mechanisms creating false positive lumpectomy margins

OBJECTIVE: All breast surgeons deal with the frustration of initial pathologic close or positive margins that have no residual cancer upon re-excision. To understand the mechanisms that create false positive margins, specimen handling was standardized in a single surgeon's practice and margin issues were tracked. METHODS: Prospectively over a 3.5-year period, needle-localized lumpectomies for the management of early-stage breast cancer were standardized in all aspects of specimen handling, including surgeon inking and specimen compression for specimen radiography for quality assurance. The current study reviews 220 such cases where the original lumpectomy included a small piece of overlying skin from over the target lesion. All specimen radiography was performed with compression at the skin to deep level to bias the "pancaking" effect of pushing tumor to specimen surface to the deep margin. RESULTS: Of the 220 therapeutic lumpectomies performed for clinical stage 0-2 breast cancer in this fashion, 175 (79.5%) had negative margins by a distance of 10 mm or more. Margins less than 10 mm were classified as close and were present in 20 (9.1%) of cases. These were heavily biased toward margins closer than 2 mm. Positive initial margins accounted for 25 (11.4%) of cases. Of the 45 close or positive margin cases, 12 involved the deep margin only, and on re-excision none was found to have residual tumor. When other single margins were involved, re-excision found tumor in 5 of 14 cases (35.7%). When multiple margins were close or positive, 9 of 19 cases (47.3%) were found to have residual tumor at re-excision. CONCLUSIONS: Specimen compression increases the incidence of false margin positivity. The best predictors of true margin positivity are multiple close or positive margins or margin positivity in a direction not associated with specimen ex vivo compression.     

Effect of reexcision on the success of breast-conserving surgery

Background: The success of lumpectomy and radiotherapy is dependent on minimizing the residual tumor burden in the breast. Histologic margin status is one measure of the extent of residual tumor. This study was undertaken to determine the success rate of a single conservative lumpectomy in obtaining negative margins and to evaluate the incidence of residual tumor after biopsies with positive or unknown margins. Methods: This is a retrospective study covering a 5-year period (June 1988–June 1993). Results: Three hundred sixteen women had lumpectomies. In 239, lumpectomy was the initial operation after a positive fine-needle aspiration or as a diagnostic procedure. Thirteen cases had positive margins. Reexcision was performed in 90 cases. The indication for reexcision was a positive margin in 42 cases (4 with gross tumor) and unknown margin status in 48. Nineteen of the reexcisions for positive margins and 20 of the reexcisions for unknown margins contained residual tumor. Eighty-six (96%) of the 90 reexcised patients underwent breast preserving surgery. Patient age, menopausal status, histologic tumor type, tumor size, and clinical presentation were not predictive of residual tumor. Conclusions: The need for reexcision does not preclude breast preservation. Because single-stage lumpectomy is successful in achieving negative margins in 95% of patients, diagnostic biopsy without margin evaluation should be abandoned to avoid routine reexcision.Results of this study were presented at the 47th Annual Meeting of The Society of Surgical Oncology, March 17–20, 1994, Houston, Texas, USA.     

Factors Associated with Negative Margins of Lumpectomy Specimen: Potential Use in Selecting Patients for Intraoperative Radiotherapy

Background Lumpectomy followed by radiation is standard treatment for early breast cancer. Recently, the use of partial breast intraoperative radiation (IORT) has been developed, and patients selected for IORT should not have positive margins. This study’s purpose was to identify factors predicting negative margins after lumpectomy. Methods Patient age, preoperative investigations, surgery, final pathology, and margin status were examined using a prospective database between 1999 and 2005. Univariate and multivariate logistic regression analysis were performed to identify patient and tumor factors predicting an increased rate of negative margins. The results were used to generate a patient selection algorithm. Results The rate of positive margins at first resection was 17% in 730 lumpectomies (708 patients). Multivariate analysis revealed that older age (P = .0006), smaller tumor size (P < .0025), type of surgery (OR = 3.4 for ultrasound vs mammogram-guided wire localization, P = .003), and having a core needle biopsy (CNB) with preoperative cancer diagnosis (P < .0001) were predictive for having a negative margin. Patients older than age 50 with a preoperative CNB showing invasive cancer less that 3 cm that can be localized under ultrasound had a negative margin rate of 98 % (n = 178). These patients would be ideal for consideration of IORT. Conclusions Negative margin rates after lumpectomy are predicted by age, tumor size, preoperative investigations, and localization technique. These variables can be used to select patients for IORT with a 2.2% chance of positive margins. Presented at the 13th Annual Meeting of the Canadian Society of Surgical Oncology, Toronto, Ontario, Canada, April 27, 2007.     

The CUBE Technique: Continuous Ultrasound-Guided Breast Excision

Background

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.

Methods

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.

Results

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.

Conclusions

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.     

Evaluation of margin status in lumpectomy specimens and residual breast carcinoma

Residual disease leads to most local recurrences, especially in those patients treated with breast-conserving therapy (BCT). This study evaluates whether assessment of excisional biopsy margins accurately predicts the presence or absence of residual tumor in the lumpectomy bed. The margin status of 201 consecutive lumpectomy specimens of 178 infiltrating and 23 in situ breast carcinomas followed by reexcision were evaluated microscopically and classified as "positive" (tumor at the inked margins), "negative" (tumor more than 0.1 cm from the inked margins), "close" (tumor within 0.1 cm of the inked margins, but not transecting it), and "indeterminate" (biopsy not inked or fragmented). Tumor size and grade were also analyzed, as potential predictors for residual disease. Residual tumor was found in 41% of the patients: in 21% of the cases with negative margins, in 63% with positive margins, in 30% with close margins, and in 56% with indeterminate margins. In 37% of the positive and 70% of the close margin cases, no tumor was found in reexcised specimens. In 24% of the cases the residual disease was composed entirely of an in situ component of the same histologic type as the initial biopsy. No relationship was found between tumor size or grade and residual disease. For breast tumors, histologically negative and "close" biopsy margins do not guarantee complete excision. A number of factors seem to be responsible for the discrepancy between the margin status and the presence/absence of residual cancer in the lumpectomy bed.     

Malignant Phyllodes Tumor of the Breast: Treatment and Prognosis

Surgery remains the mainstay of the treatment in patients with malignant phyllodes tumor of the breast (MPTB); however, the extent of surgery (breast conserving surgery [BCS] versus mastectomy) and the role of adjuvant radiotherapy have been controversial. We report a single institution's experience with MPTB. We discuss controversial therapeutic aspects of this rare tumor. Seventy patients with MPTB treated primarily with surgery were evaluated. The mean age was 50 years (21–76), and the mean size of the tumor was 6 cm. Thirty‐four (48.6%) patients were treated with total mastectomy, and 36 (51.4%) were treated with BCS (lumpectomy or wide local excision). Microscopic surgical margins were free of tumor in all cases. In 64 (91.4%) patients, margins were ≥1 cm. Remaining 6 (8.6%) patients treated with BCS margins were <1 cm and subsequently radiotherapy was performed. Among 70 patients, 58 (82.9%) had no evidence of disease (NED) after 5 years. The extent of surgery was not significantly related to the 5‐year NED survival rates (82.4% in patients who underwent mastectomy and 83.3% in patients who underwent BCS only or BCS with adjuvant irradiation). The 5‐year NED survival rates in BCS (tumor‐free margin ≥1 cm) and BCS with irradiation (tumor‐free margin <1 cm) groups were identical (83.3%). Our data support the potential use of BCS in patients with MPTB. Mastectomy is indicated only if tumor‐free margins cannot be obtained by BCS. Adjuvant radiotherapy may be considered if tumor‐free margins are <1 cm.     

Breast-conserving Therapy for Palpable and Nonpalpable Breast Cancer: Can Surgical Residents Do the Job Irrespective of Experience?

Background

The aim of this study was to evaluate the influence of operative experience in obtaining tumor-free margins in breast-conserving therapy. In the case of palpable breast cancers, lumpectomies can safely be performed by any surgical resident. For nonpalpable breast cancers, lumpectomies should be treated only by senior residents or attending surgeons, even if supervision during the operation is given by an attending surgeon for junior residents. Radicality of breast carcinoma excision, defined by the tumor-free margin of the removed specimen has been determined to be the major prognostic factor for local recurrence. The aim of this study was to evaluate the influence of operative experience in obtaining tumor-free margins in breast-conserving therapy (BCT). Can lumpectomy for breast carcinoma be performed by surgical residents safely?

Methods

All lumpectomies for breast carcinoma between 1999 and 2003 were included out of a prospective database of a single institution. Radicality of resection and patient and histopathologic tumor characteristics were analyzed for 660 lumpectomies. Operative experience of the surgeon performing the lumpectomy was staged as junior residents (JR, years 1–3 in residency), senior residents (SR; years 4–6 in residency), and attending surgeon (AS).

Results

A significant difference in obtaining tumor-free margins for palpable tumors was found between ASs (81%) vs. SRs assisted by another resident (92%). For nonpalpable tumors, a significant difference was found in two groups: (1) SRs assisted by another surgical resident (86%) vs. JRs assisted by another surgical resident (61%) and (2) ASs (83%) vs. JRs assisted by another resident (61%) or assisted by an AS (73%).

Conclusion

Surgical residents can safely perform BCT in patients with palpable breast cancer. The level of experience has no statistical significance for palpable tumors in a high-volume center. Nonpalpable lesions should be treated only by SRs or ASs.

     

The Role of Frozen Section Analysis of Margins during Breast Conversation Surgery

abstract Purpose. The role of frozen section analysis during breast conversation surgery is undefined. Assessment of margins using eprmanent section evaluation is the standard method of ensuring complete tumor excision. If the margin is positive, however, surgical re-excision is necessary to reduce the likelihood of subsequent local recurrence. Therefore, biopsy of the surgical cavity with immediate pathological evaluation during lumpectomy was performed to evaluate the effect on local recurrence, the number of re-excisions, and cosmesis. Patients and Methods. One hundred sixty patients underwent attempted lumpectomy with frozen section margin determination. One hundred forty patients were available for long-term follow-up (mean = 57 months, median = 46 months). All patients underwent attempted breast conservation surgery, which consisted of tumorectomy with excision of a greater than 1-cm rim of grossly normal tissue. Tumor margins were obtained by intraoperative biopsy with frozen section analysis of the lumpectomy cavity walls. Results. In 21 patients (15%), frozen section analyses (FSA) revealed positive margins, resulting in immediate re-excision. In seven of these patients (%), margins were persistetly positive, and these patients therefore underwent mastectomy. Fourteen patients were successfully re-excised to a negative margin. The sensitivity and specificity of FSA were 91% and 100%, respectively. Five percent of patients definitively managed by lumpectomy with FSA of margins recurred locally. The mean cosmesis score after radiotherapy was 7.0 out of a possible 10, correlating with a good to excellent result. Discussion. The accuracy of FSA, low recurrence rate, avoidance of reoperation, and good cosmesis indicate that intraoperative frozen section analysis should be adopted as a safe and effective method of margin analysis during breast conservation surgery.     

Radiographically guided shave margins may reduce lumpectomy re‐excision rates

Minimizing margin re‐excision optimizes patient care by providing appropriate oncologic resection and reducing costs. This study aims to assess margin positivity rate in two groups: shave margin based on gross specimen (control group, CG) vs shave margin based on intraoperative imaging (radiographic group, RG). A total of 182 patients who underwent lumpectomy for stage O‐III breast cancer at a single institution from January 2013 to January 2014 were evaluated. There was statistically significant decrease in margin re‐excision rate with intraoperative mammography but not with ultrasound. Surgeons are ideally equipped to use intraoperative imaging to guide margin excision, thus, improving care and reducing costs.     

A comparison of ink-directed and traditional whole-cavity re-excision for breast lumpectomy specimens with positive margins

Background: Excising a breast tumor with negative margins minimizes local recurrence. With a positive margin, the standard re-excision consists of excising the whole cavity and all surrounding breast tissue. By marking the sides of the lumpectomy specimen with six different colored inks, the surgeon can limit the re-excision to the involved margin. We compared the local recurrence rate after these two re-excision methods.Methods: Records were reviewed of 527 women (546 breasts) treated with lumpectomy at two institutions. The log-rank test was used to compare the local recurrence–free survival.Results: Of 546 tumors, 245 (45%) had negative margins on the initial lumpectomy and were not re-excised. Fifty-five percent had a positive or close margin; 181 underwent whole-cavity re-excision, and 120 had ink-directed re-excision. The mean follow-up time was 3.4 years. There was no significant difference in local recurrence for the patients whose initial margin was negative (3.7%) compared with the 243 patients with initially positive margins who underwent a re-excision (3.3%). Eleven of 181 (6%) patients undergoing a whole-cavity re-excision developed a local recurrence, compared with none of 120 (0%) patients with an ink-directed re-excision (P = not significant). Tissue mass excised was significantly smaller in the ink-directed group (23 vs. 83 g, P < .05).Conclusions: Ink-directed re-excision of lumpectomy specimens with positive margins minimizes the amount of breast tissue removed without increasing the incidence of local recurrence and is therefore preferable to the standard whole-cavity method.     

The Use of Oncoplastic Reduction Techniques to Reconstruct Partial Mastectomy Defects in Women with Ductal Carcinoma In Situ

Abstract: The application of oncoplastic techniques to breast conservation therapy (BCT) is thought to improve cosmetic results with some documented oncologic advantages in certain patients. Although present data highlight the oncologic safety of this approach, the role of oncoplastic surgery specific to ductal carcinoma in situ (DCIS) has not been elucidated. In this study, all women in the Emory Healthcare system between January 1991 and June 2006 with biopsy‐proven DCIS who underwent lumpectomies combined with simultaneous reduction mammaplasties or mastopexies were identified. Medical records, including office notes, operative and pathology reports were analyzed. Parameters included age, BMI, histologic grade (low, intermediate, high) and type (comedo versus non‐comedo) of DCIS, margin status, locoregional recurrence, specimen weight, postoperative complications, and overall outcomes. Pedicle design and contralateral breast pathology were also analyzed. Twenty‐eight women were included in the study with an average age of 47. Therapeutic mammaplasty was the definitive procedure for 18 (64%) of these patients. Ten patients (36%) required reoperations: nine for positive margins and one for residual microcalcifications (stereo biopsy DCIS). Overall, seven patients (25%) required completion mastectomy with reconstruction (transverse rectus abdominus myocutaneous flap: n = 3, latissimus flap: n = 4), whereas three patients (11%) underwent re‐excisions with confirmation of negative margins. All ten women who required completion mastectomy or re‐excisions exhibited either intermediate or high‐grade, comedo DCIS. Overall, 50% (6/12) of women diagnosed with high‐grade comedo DCIS required completion mastectomy with reconstruction after initial therapeutic mammaplasty. The final positive‐margin rate for women diagnosed with intermediate‐grade, comedo necrosis was 43% (3/7). The women in this failed group that required reoperations were overall younger (mean: 45.6; median: 43) than those in which oncoplastic surgery was the definitive procedure (mean: 57.8; median: 57). There were no significant differences between the failed and successful groups in terms of biopsy weight (failed: 253 g, successful: 237 g), type of excision (e.g., wire‐localized), location of tumor, reduction type (e.g., superior medial), or postoperative complications. There was one case of locoregional recurrence of DCIS 7 months after the initial operation. All 28 patients had no evidence of disease at an average follow‐up of 2.7 years. This study suggests that although oncoplastic reduction techniques are a reasonable approach for women with DCIS, stricter patient selection and improved confirmation of negative margins will minimize the need for either re‐excisions or completion mastectomy and reconstruction.     

Extent of Lumpectomy for Breast Cancer After Diagnosis by Stereotactic Core Versus Wire Localization Biopsy

Background: Stereotactic core biopsy of mammographically defined breast abnormalities is an alternative to wire localization biopsy. The purpose of this study was to evaluate the extent of lumpectomy in patients diagnosed by stereotactic core versus wire localization biopsy.Methods: A total of 67 consecutive patients diagnosed with invasive cancers or ductal carcinoma in situ (DCIS) were retrospectively reviewed. Thirty-four were diagnosed by core biopsy and the remaining 33 by wire localization biopsy.Results: Approximately 65% of patients subsequently had breast-conserving surgical therapy. Seventy-nine percent of patients undergoing wire localization biopsies had positive surgical margins. Achievement of negative surgical margins for lumpectomies performed after wire localization or stereotactic core biopsies was 100% and 89%, respectively, which was not significantly different. However, the total volume of breast tissue removed for breast conservation in patients undergoing lumpectomy after wire localization versus core biopsies was 183 cm³ and 104 cm³, respectively, which was significantly different (P = .003).Conclusions: Diagnosis by stereotactic core biopsies resulted in less tissue removal to achieve margin-negative lumpectomies for breast conservation. Stereotactic core biopsy is the method of choice for biopsying nonpalpable, suspicious breast lesions.     

Tumour involvement of the re-excision specimen following clear local excision of breast cancer with positive margins

Background: Breast conservation surgery and subsequent radiotherapy is an acceptable method of treating breast cancer. Complete excision of the primary tumour is important to minimize the risk of local recurrence. Re‐excision is usually carried out if the initial primary tumour excision shows positive margins. However, a significant proportion of re‐excision specimens are negative for tumour. The aim of the present study was to identify factors predicting a histologically positive re‐excision specimen. Methods: The case records of all patients with invasive and in situ breast cancer referred to the William Buckland Radiotherapy Centre between January 1996 and December 2001 were reviewed. The factors evaluated were patient age, whether or not tumours were detected by screening mammography, use of hook‐wire needle localization, whether tumours were marked with orientating sutures, histopathological characteristics of the tumour and involvement of axillary nodes. Univariate analysis was performed. Results: In the study period, a total of 1128 patients were reviewed. Of these, 742 underwent breast conservation surgery. Twenty‐nine (3.9%) of the 742 had positive surgical margins and underwent re‐excision. Data were insufficient for six, leaving 23 patients eligible for the study. The number of patients entering the study was small, limiting the statistical analysis. Of these, 21 patients had invasive cancer and two patients had ductal carcinoma in situ only. Of 23 re‐excisions, 11(48%) contained residual tumour. Univariate analysis of the data revealed no significant factors that were likely to predict tumour in the re‐excision specimen. The local recurrence after re‐excision in patients with positive margins was 4.3%. Conclusion: The results suggest that it is not possible to predict which patients will have tumour in the re‐excision specimen. However, approximately 50% of re‐excision specimens showed residual cancer. Therefore it is recommended that all excisions with positive margins need further surgery.     

Association of Clinical and Pathologic Variables with Lumpectomy Surgical Margin Status after Preoperative Diagnosis or Excisional Biopsy of Invasive Breast Cancer

Purpose To evaluate the impact of preoperative diagnosis in obtaining negative lumpectomy margins. Materials and Methods Five hundred and thirty five patients who underwent breast conserving therapy for stage I/II cancer from 1971 to 1996 were included in this IRB-approved retrospective analysis. Three hundred and ninety five patients had a defined inked margin status after initial excision. The following factors were evaluated for correlation with margins at initial excision: age (< or >45), grade (3/1 or 2), family history (present/absent), histology (lobular/other), estrogen receptor (ER) status, presence of extensive intraductal carcinoma (EIC), presence of lymphovascular invasion (LVI), and biopsy type (excisional/preoperative). Results Biopsy type (P < 0.0001), EIC (P = 0.002), ER status (P = 0.02), lobular histology (P = 0.02) and age (P = 0.02) were significantly correlated with initial margin status among the entire group. For patients who underwent preoperative diagnostic biopsy, 52% (35/67) had negative initial margins as compared to 29% (94/328) for excisional biopsy. Among patients who underwent preoperative biopsy, only lobular histology (P = 0.04) and LVI (P = 0.04) were related to initial margin status. The rate of re-excision was 34% for patients diagnosed preoperatively versus 61% with excisional biopsy (P < 0.0001). The percentage of patients with negative final margin status was similar with either core/needle or excisional biopsy (79 and 78%, respectively). Conclusions Preoperative diagnosis is the most significant predictor of initial margin status in patients undergoing breast conservation. Patients with lobular histology may require improved preoperative and/or intraoperative assessment to increase the rate of negative margins at initial excision.     

The influence of additional surgical margins on the total specimen volume excised and the reoperative rate after breast-conserving surgery

BACKGROUND: It is unclear whether the additional removal of breast tissue during breast-conserving therapy (BCT) for breast cancer beyond the standard lumpectomy reduces the incidence of inadequate microscopic margins found at pathological examination and subsequent reoperation. This study compares the reoperative rates after initial BCT in 3 groups of patients who underwent lumpectomy with complete resection of 4 to 6 additional margins, lumpectomy with selective resection of 1 to 3 additional margins, or standard lumpectomy. METHODS: Retrospective data were reviewed from 171 selected cases of BCT, from May 2000 to February 2006. Forty-five cases involved lumpectomy with complete resection of 4 to 6 additional margins; 77 involved lumpectomy with selective resection of 1 to 3 additional margins, whereas 49 involved standard lumpectomy. All samples underwent pathologic analysis of inked resection margins by permanent section. The 3 groups were compared for patient demographics, tumor size and histologic subtype, tumor stage, margin status, excised specimen volume, and eventual subsequent reoperation. Adequate surgical margin was defined as any negative margin greater than 2 mm. RESULTS: The group with complete resection of 4 to 6 additional margins had a subsequent reoperation rate of 17.7%, whereas the group with selective resection of 1 to 3 additional margins and the standard lumpectomy group had a subsequent reoperation rate of 32.5% and 38.7%, respectively, because of inadequate margins. The mean total excised specimen volume in the 3 groups was 129.19, 46.04, and 37.44 cm3, respectively. CONCLUSIONS: The complete resection of 4 to 6 additional margins during the initial BCT resulted in the lowest subsequent reoperation rate, and the largest total volume specimen excised among the 3 techniques studied.     

The malignant degeneration of a phyllode tumour in man: A case report

IntroductionMalignant phyllodes tumours of the breast represent less than 1% of all breast cancers.Few cases of phyllodes tumours have been reported in men.Case presentationWe present the case of a 60-year-old man who was operated on one year ago for a breast tumour that had undergone a lumpectomy with an anatomopathological study in favour of a grade 2 phylloid tumour. He was admitted to hospital with a palpable mass in his right breast. The lumpectomy enlarged to the right pectoralis major muscle was then performed with clear surgical margins.Microscopic examination revealed high-grade malignant phyllodes.Postoperatively, after 3 months, the patient was given a breast MRI and a PET/CT scan which returned without abnormalities.The patient is followed for eight months and has shown no signs of recurrence.DiscussionMalignant phyllodes tumours of the breast show clinical and mammographic signs comparable to those of benign lesions.The diagnosis is confirmed by histology, treatment is based on surgery, which may be a large lumpectomy or mastectomy, and the prognosis depends on several factors, the most important of which is the margin for surgical resection.ConclusionThe best treatment is a wide local excision with a safety margin of 1 cm, unless it is metastatic.Early diagnosis and surgery improves the prognosis.     

Extreme Oncoplasty: Breast Conservation for Patients Who Need Mastectomy

Extreme oncoplasty is a breast conserving operation, using oncoplastic techniques, in a patient who, in most physicians' opinions, requires a mastectomy. These are generally large, greater than 5 cm multifocal or multicentric tumors. Many will have positive lymph nodes. Most will require radiation therapy, even if treated with mastectomy. Sixty‐six consecutive patients with multifocal, multicentric, or locally advanced tumors that spanned more than 50 mm were studied (extreme cases). All patients underwent excision and oncoplastic reconstruction using a standard or split wise pattern reduction and immediate contralateral surgery for symmetry. All received postexcisional standard whole breast radiation therapy with a boost to the tumor bed. The extreme cases were compared with 245 consecutive patients with unifocal or multifocal tumors that spanned 50 mm or less (standard cases). All extreme patients were advised to have a mastectomy; all sought a breast conserving second opinion. Diagnostic evaluation included digital mammography, ultrasound, MRI, and PET‐CT (if invasive). Standard cases did extremely well. No ink on tumor was achieved 96% of the time among 245 patients. The median tumor size was 21 mm (mean 23 mm). Margins equal or greater than 1 mm were achieved in 88.6% of patients. Seventeen (6.9%) standard patients underwent re‐excision to achieve wider margins and only one patient (0.4%) was converted to mastectomy. With 24 months of median follow‐up, three patients (1.2%) experienced local recurrence. For extreme cases, no ink on tumor was achieved 83.3% of the time, which is comparable to published positive margin rates after standard lumpectomy. The median tumor size was 62 mm (mean 77 mm). Margins equal or greater than 1 mm were achieved in 54.5% of patients. Six (9.1%) extreme patients underwent re‐excision to achieve wider margins and four patients (6.1%) were converted to mastectomy. With a follow‐up of 24 months, one patient (1.5%) experienced a local recurrence. Extreme oncoplasty is a promising new concept. It allows successful breast conservation in selected patients with greater than 5 cm multifocal/multicentric tumors. It may be useful in patients with locally advanced tumors following neo‐adjuvant chemotherapy. From a quality of life point of view, it is a better option than the combination of mastectomy, reconstruction, and radiation therapy. Long‐term data on recurrence and survival are not available, using this approach. Based on historical data, it is expected the local recurrence will be somewhat higher but that there will be little or no impact on survival.     

A Study of the Growth Patterns of Breast Carcinoma Using 3D Reconstruction: A Pilot Study

Lumpectomy with microscopically clear margins is a safe and effective approach for surgical management of breast carcinoma. Margins are positive for tumor in 18–50% of lumpectomies, as it is not possible to accurately determine the shape or microscopic borders of a tumor preoperatively or intraoperatively. We examined the 3D microanatomy and growth patterns of common breast carcinoma subtypes to provide guidance for lumpectomy surgery. Prospective consent was obtained for the use of excess tissue from patients undergoing lumpectomy or mastectomy for breast carcinoma. Tissue blocks from nine breast carcinomas were serially sectioned. Hematoxylin and eosin‐stained slides at 100 μm intervals were scanned using a Nanozoomer (Hamamatsu, Japan) microscopic‐resolution scanner. Three‐dimensional reconstructions of tumors were created from scanned images using Reconstruct, open‐access software. Breast carcinoma subtypes demonstrated characteristic growth patterns within breast tissue, which may have implications for lumpectomy surgery. Invasive ductal carcinomas showed a spherical shape, with a spiculated surface representing tumor cells infiltrating into surrounding parenchyma. Ductal carcinoma in situ appeared to spread along the duct system, creating dilated, tortuous, tumor‐filled ducts. The invasive lobular carcinomas examined had a haphazard, linear, infiltrative growth pattern, different from the shape seen in ductal carcinomas. Our preliminary work suggests that invasive ductal and invasive lobular carcinomas appear to have distinct growth patterns in three dimensions and ductal carcinoma in situ appears to grow in a linear fashion along the duct network. The microanatomy studies described have the potential to guide refinements in breast lumpectomy technique.     

Identifying Factors and Techniques to Decrease the Positive Margin Rate in Partial Mastectomies: Have We Missed the Mark?

Breast conservation therapy (BCT) has a reported incidence of positive margins ranging widely in the literature from 20% to 70%. Efforts have been made to refine standards for partial mastectomy and to predict which patients are at highest risk for incomplete excision. Most have focused on histology and demographics. We sought to further define modifiable risk factors for positive margins and residual disease. A retrospective study was conducted of 567 consecutive partial mastectomies by 21 breast and general surgeons from 2009 to 2012. Four hundred fourteen cases of neoplasm were reviewed for localization, intraoperative assessment, excision technique, rates, and results of re‐excision/mastectomy. Histologic margins were positive in 23% of patients, 25% had margins 0.1–0.9 mm, and 7% had tumor within 1–1.9 mm. Residual tumor was identified at—in 61 cases: 38% (disease at margin), 21% (0.1–0.9 mm), and 14% (1–1.9 mm). Ductal carcinoma in situ (DCIS) was present in 85% of residual disease on re‐excision and correlated to higher rates of re‐excision (p = <0.001), residual disease, and subsequent mastectomy. The use of multiple needles to localize neoplasms was associated with 2–3 times the likelihood for positive margins than when a single needle was required. The removal of additional margins at initial surgery correlated with improved rates of complete excision when DCIS was present. Patients must have careful analysis of specimen margins at the time of surgery and may benefit from additional tissue excision or routine shaving of the cavity of resection. Surgeons should conduct careful patient selection for BCT, in the context of multifocal, and multicentric disease. Patients for whom tumor localization requires bracketing may be at higher risk for positive margins and residual disease and should be counseled accordingly.