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Breast Cancer Research and Treatment

, Volume 158, Issue 3, pp 535–541 | Cite as

Ultrasound-guided breast-conserving surgery for early-stage palpable and nonpalpable invasive breast cancer: decreased excision volume at unchanged tumor-free resection margin

  • W. A. Slijkhuis
  • E. M. Noorda
  • H. van der Zaag-Loonen
  • M. J. Bolster-van Eenennaam
  • K. E. Droogh-de Greve
  • W. B. Lastdrager
  • J. W. C. Gratama
Clinical trial

Abstract

Ultrasound guidance (USG) during breast-conserving surgery improves tumor-free surgical resection margins. The objective of this study was to evaluate whether USG reduces resection volumes without compromising margin status. 134 patients with palpable or nonpalpable T1–2N0–1 invasive breast cancer were treated with USG and compared with a historical reference control group (CON) consisting of palpation-guided (PAG) or wire-guided localization (WIG) breast-conserving surgery. Primary outcomes were excess resection volume and clear margin status, and secondary outcome was re-excision rate. 66 patients underwent USG. In the CON group (n = 68), PAG was performed in 24 (35 %) and WIG in 44 (64 %) patients. Median excision volume [39 (IQR 20–66) vs 56 (38–94) cm3; p = 0.001] and median calculated resection ratio [1.7 (1.0–2.9) vs 2.8 (1.4–4.6) (p = 0.005)] were significantly smaller in the USG than in the CON group. Median minimal distance to the resection margin [4 mm (IQR 2–5 mm) vs 2 mm (1–4 mm), p = 0.004] was significantly larger. Clear resection margins were achieved in 58 of the USG patients (88 %) and in 58 of the CON patients (86 %) (p = 0.91); this was true in patients with palpable as well as nonpalpable lesions. Reexcision was needed in 6.1 and 7.2 % respectively. Relative risk for re-excision in the USG group was 0.82 (95 % CI 0.23–2.93). In patients with palpable and nonpalpable breast cancers, USG allows for lower excision volume and reduced resection of healthy breast tissue, without increased re-excision rate.

Keywords

Breast cancer Breast-conserving surgery Ultrasound 

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

References

  1. 1.
    Cochrane RA, Valasiadou P, Wilson AR, Al-Ghazal SK, Macmillan RD (2003) Cosmesis and satisfaction after breast-conserving surgery correlates with the percentage of breast volume excised. Br J Surg 90(12):1505–1509CrossRefPubMedGoogle Scholar
  2. 2.
    Haloua MH, Volders JH, Krekel NM, Barbé E, Sietses C, Jóźwiak K, Meijer S, van den Tol MP (2016) A nationwide pathology study on surgical margins and excision volumes after breast-conserving surgery: there is still much to be gained. Breast 25:14–21CrossRefPubMedGoogle Scholar
  3. 3.
    Al-Ghazal SK, Blamey RW, Stewart J, Morgan AA (1999) The cosmetic outcome in early breast cancer treated with breast conservation. Eur J Surg Oncol 25(6):566–570CrossRefPubMedGoogle Scholar
  4. 4.
    Waljee JF, Hu ES, Newman LA, Alderman AK (2008) Predictors of re-excision among women undergoing breast-conserving surgery for cancer. Ann Surg Oncol 15(5):1297–1303CrossRefPubMedGoogle Scholar
  5. 5.
    Haloua MH, Volders JH, Krekel NM, Lopes Cardozo AM, de Roos WK, de Widt-Levert LM, van der Veen H, Rijna H, Bergers E, Jóźwiak K, Meijer S, van den Tol P (2016) Intraoperative ultrasound guidance in breast-conserving surgery improves cosmetic outcomes and patient satisfaction: results of a multicenter randomized controlled trial (COBALT). Ann Surg Oncol 23(1):30–37Google Scholar
  6. 6.
    National Breast Cancer Organization of the Netherlands. Guideline breast cancer. http://www.oncoline.nl. Accessed 4 Jan 2013
  7. 7.
    van der Heiden-van der Loo M, de Munck L, Visser O, Westenend PJ, van Dalen T, Menke MB, Rutgers EJ, Peeters PH (2012) Variation between hospitals in surgical margins after first breast-conserving surgery in the Netherlands. Breast Cancer Res Treat 131(2):691–698CrossRefPubMedGoogle Scholar
  8. 8.
    Vrieling C, Collette L, Fourquet A, Hoogenraad WJ, Horiot JH, Jager JJ, Pierart M, Poortmans PM, Struikmans H, Maat B, Van Limbergen E, Bartelink H (2000) The influence of patient, tumor and treatment factors on the cosmetic results after breast-conserving therapy in the EORTC ‘boost vs no boost’ trial. EORTC radiotherapy and breast cancer cooperative groups. Radiother Oncol 55(3):219–232CrossRefPubMedGoogle Scholar
  9. 9.
    Harris JR, Levene MB, Svensson G, Hellman S (1979) Analysis of cosmetic results following primary radiation therapy for stages I and II carcinoma of the breast. Int J Radiat Oncol Biol Phys 5(2):257–261CrossRefPubMedGoogle Scholar
  10. 10.
    Pleijhuis RG, Graafland M, de Vries J, Bart J, de Jong JS, van Dam GM (2009) Obtaining adequate surgical margins in breast-conserving therapy for patients with early-stage breast cancer: current modalities and future directions. Ann Surg Oncol 16(10):2717–2730CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Krekel NM, Zonderhuis BM, Stockmann HB, Schreurs WH, van der Veen H, de Lange de Klerk ES, Meijer S, van den Tol MP (2011) A comparison of three methods for nonpalpable breast cancer excision. Eur J Surg Oncol 37(2):109–115CrossRefPubMedGoogle Scholar
  12. 12.
    Homer MJ, Smith TJ, Safaii H (1992) Prebiopsy needle localization. Methods, problems, and expected results. Radiol Clin North Am 30(1):139–153PubMedGoogle Scholar
  13. 13.
    Snider HC Jr, Morrison DG (1999) Intraoperative ultrasound localization of nonpalpable breast lesions. Ann Surg Oncol 6(3):308–314CrossRefPubMedGoogle Scholar
  14. 14.
    Barentsz MW, van Dalen T, Gobardhan PD, Bongers V, Perre CI, Pijnappel RM, van den Bosch MA, Verkooijen HM (2012) Intraoperative ultrasound guidance for excision of non-palpable invasive breast cancer: a hospital-based series and an overview of the literature. Breast Cancer Res Treat 135(1):209–219CrossRefPubMedGoogle Scholar
  15. 15.
    Krekel NM, Haloua MH, Lopes Cardozo AM, de Wit RH, Bosch AM, de Widt-Levert LM, Muller S, van der Veen H, Bergers E, de Lange de Klerk ES, Meijer S, van den Tol SMP (2013) Intraoperative ultrasound guidance for palpable breast cancer excision (COBALT trial): a multicentre, randomised controlled trial. Lancet Oncol 14(1):48–54CrossRefPubMedGoogle Scholar
  16. 16.
    Eichler C, Hübbel A, Zarghooni V, Thomas A, Gluz O, Stoff-Khalili M, Warm M (2012) Intraoperative ultrasound: improved resection rates in breast-conserving surgery. Anticancer Res 32(3):1051–1056PubMedGoogle Scholar
  17. 17.
    Pan H, Wu N, Ding H, Ding Q, Dai J, Ling L, Chen L, Zha X, Liu X, Zhou W, Wang S (2013) Intraoperative ultrasound guidance is associated with clear lumpectomy margins for breast cancer: a systematic review and meta-analysis. PLoS One 8(9):74028CrossRefGoogle Scholar
  18. 18.
    Volders JH, Haloua MH, Krekel NM, Meijer S, van den Tol PM (2016) Current status of ultrasound-guided surgery in the treatment of breast cancer. World J Clin Oncol 7(1):44–53CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Ahmed M, Douek M (2013) Intra-operative ultrasound versus wire-guided localization in the surgical management of non-palpable breast cancers: systematic review and meta-analysis. Breast Cancer Res Treat 140(3):435–446CrossRefPubMedGoogle Scholar
  20. 20.
    Olivotto IA, Rose MA, Osteen RT, Love S, Cady B, Silver B, Recht A, Harris JR (1989) Late cosmetic outcome after conservative surgery and radiotherapy: analysis of causes of cosmetic failure. Int J Radiat Oncol Biol Phys 17(4):747–753CrossRefPubMedGoogle Scholar
  21. 21.
    Krekel NM, van Slooten HJ, Barbé E, de Lange de Klerk ES, Meijer S, van den Tol MP (2012) Is breast specimen shrinkage really a problem in breast-conserving surgery? J Clin Pathol 65(3):224–227CrossRefPubMedGoogle Scholar
  22. 22.
    Krekel N, Zonderhuis B, Muller S, Bril H, van Slooten HJ, de Lange de Klerk E, van den Tol P, Meijer S (2011) Excessive resections in breast-conserving surgery: a retrospective multicentre study. Breast J 17(6):602–609CrossRefPubMedGoogle Scholar
  23. 23.
    Paramo JC, Landeros M, McPhee MD, Mesko TW (1999) Intraoperative ultrasound-guided excision of nonpalpable breast lesions. Breast J 5(6):389–394CrossRefPubMedGoogle Scholar
  24. 24.
    Bennett IC, Greenslade J, Chiam H (2005) Intraoperative ultrasound-guided excision of nonpalpable breast lesions. World J Surg 29(3):369–374CrossRefPubMedGoogle Scholar
  25. 25.
    Moore MM, Whitney LA, Cerilli L, Imbrie JZ, Bunch M, Simpson VB, Hanks JB (2001) Intraoperative ultrasound is associated with clear lumpectomy margins for palpable infiltrating ductal breast cancer. Ann Surg 233(6):761–768CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Eggemann H, Ignatov T, Beni A, Costa SD, Ignatov A (2014) Ultrasonography-guided breast-conserving surgery is superior to palpation-guided surgery for palpable breast cancer. Clin Breast Cancer 14(1):40–45CrossRefPubMedGoogle Scholar
  27. 27.
    Davis KM, Hsu CH, Bouton ME, Wilhelmson KL, Komenaka IK (2011) Intraoperative ultrasound can decrease the re-excision lumpectomy rate in patients with palpable breast cancers. Am Surg 77(6):720–725PubMedGoogle Scholar
  28. 28.
    Eggemann H, Costa SD, Ignatov A (2016) Ultrasound-guided versus wire-guided breast-conserving surgery for nonpalpable breast cancer. Clin Breast Cancer 16(1):1–6CrossRefGoogle Scholar
  29. 29.
    Morris OJ, Knight V, Logan D (2014) Intra-operative ultrasound versus wire-guided localization in the surgical management of non-palpable breast cancer. Breast Dis 34(4):157–163CrossRefPubMedGoogle Scholar
  30. 30.
    Moore MM, Borossa G, Imbrie JZ, Fechner RE, Harvey JA, Slingluff CL Jr, Adams RB, Hanks JB (2000) Association of infiltrating lobular carcinoma with positive surgical margins after breast-conservation therapy. Ann Surg 231(6):877–882CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Fisher CS, Mushawah FA, Cyr AE, Gao F, Margenthaler JA (2011) Ultrasound-guided lumpectomy for palpable breast cancers. Ann Surg Oncol 18(11):3198–3203CrossRefPubMedGoogle Scholar
  32. 32.
    Johnson K, Sarma D, Hwang ES (2015) Lobular breast cancer series: imaging. Breast Cancer Res 11(17):94CrossRefGoogle Scholar
  33. 33.
    Kombar OR, Fahmy DM, Brown MV, Farouk O, El-Damshety O (2012) Sonomammographic characteristics of invasive lobular carcinoma. Breast Cancer (Dove Med Press) 30(4):115–124Google Scholar
  34. 34.
    Butler RS, Venta LA, Wiley EL, Ellis RL, Dempsey PJ, Rubin E (1999) Sonographic evaluation of infiltrating lobular carcinoma. Am J Roentgenol 172(2):325–330CrossRefGoogle Scholar
  35. 35.
    Porter AJ, Evans EB, Foxcroft LM, Simpson PT, Lakhani SR (2014) Mammographic and ultrasound features of invasive lobular carcinoma of the breast. J Med Imaging Radiat Oncol 58(1):1–10CrossRefPubMedGoogle Scholar
  36. 36.
    Cardoso MJ, Oliveira H, Cardoso J (2014) Assessing cosmetic results after breast conserving surgery. J Surg Oncol 110(1):37–44CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • W. A. Slijkhuis
    • 1
  • E. M. Noorda
    • 2
  • H. van der Zaag-Loonen
    • 3
  • M. J. Bolster-van Eenennaam
    • 4
  • K. E. Droogh-de Greve
    • 1
  • W. B. Lastdrager
    • 4
  • J. W. C. Gratama
    • 1
  1. 1.Department of RadiologyGelre Hospital ApeldoornUtrechtThe Netherlands
  2. 2.Department of SurgeryIsala KliniekenZwolleThe Netherlands
  3. 3.Department of EpidemiologyGelre Hospital ApeldoornUtrechtThe Netherlands
  4. 4.Department of SurgeryGelre Hospital ApeldoornUtrechtThe Netherlands

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