Annals of Surgical Oncology

, Volume 23, Issue 9, pp 2788–2794 | Cite as

The Role of Intraoperative Pathologic Assessment in the Surgical Management of Ductal Carcinoma In Situ

  • Marquita R. DeckerEmail author
  • Amy Trentham-Dietz
  • Noelle K. Loconte
  • Heather B. Neuman
  • Maureen A. Smith
  • Rinaa S. Punglia
  • Caprice C. Greenberg
  • Lee G. Wilke
Breast Oncology



Re-excision surgeries for the treatment of ductal carcinoma in situ (DCIS) put a strain on patients and healthcare resources; however, intraoperative pathologic assessment of DCIS may lead to a reduction in these additional surgeries. This study examined the relationship between intraoperative pathologic assessment and subsequent operations in patients with a diagnosis of DCIS.


Surveillance, Epidemiology, and End Results—Medicare patients diagnosed with DCIS from 1999 to 2007 who initially underwent partial mastectomy, without axillary surgery, were included in this study. Use of intraoperative frozen section or touch preparation during the initial surgery was assessed. Multivariable logistic regression was used to describe the relationship between the use of intraoperative pathologic assessment and any subsequent mastectomy or partial mastectomy within 90 days of the initial partial mastectomy.


Of 8259 DCIS patients, 3509 (43 %) required a second surgery, and intraoperative pathologic assessment was performed for 2186 (26 %). Intraoperative pathologic assessment had no statistically significant effect on whether or not a subsequent breast surgery occurred (adjusted odds ratio 1.07, 95 % confidence interval 0.95–1.21; p = 0.293). Patient residence in a rural area, tumor size ≥2 cm, and poorly differentiated tumor grade were associated with a greater likelihood of subsequent surgery, while age 80 years and older was associated with a lower likelihood of subsequent surgery.


The use of intraoperative frozen section or touch preparation during partial mastectomy from 1999 to 2007 was not associated with a reduction in subsequent breast operations in women with DCIS. These results highlight the need to identify cost-effective tools and strategies to reduce the need for additional surgery in patients with DCIS.


Sentinel Lymph Node Current Procedural Terminology Partial Mastectomy Touch Preparation Restrictive Inclusion Criterion 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



This project was supported by the University of Wisconsin Carbone Cancer Center (UWCCC) support grant from the National Cancer Institute–National Institutes of Health (NCI–NIH) [Grant Number P30 CA014520-34]. Additional support was provided by the Health Innovation Program, the University of Wisconsin School of Medicine and Public Health from The Wisconsin Partnership Program, and the Community–Academic Partnerships core of the University of Wisconsin Institute for Clinical and Translational Research (UW ICTR) through the National Center for Advancing Translational Sciences (NCATS) [Grant UL1TR000427]. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. This study used the linked SEER–Medicare database. The interpretation and reporting of these data are the sole responsibility of the authors. The authors acknowledge the efforts of the Applied Research Program, NCI; the Office of Research, Development and Information, CMS; Information Management Services, Inc. (IMS); and the SEER Program tumor registries in the creation of the SEER–Medicare database. The collection of the California cancer incidence data used in this study was supported by the California Department of Public Health as part of the statewide cancer reporting program mandated by California Health and Safety Code Sect. 103885; the NCI’s SEER Program under contract N01-PC-35136 awarded to the Northern California Cancer Center, contract N01-PC-35139 awarded to the University of Southern California, and contract N02-PC-15105 awarded to the Public Health Institute; and the Centers for Disease Control and Prevention’s National Program of Cancer Registries, under agreement #U55/CCR921930-02 awarded to the Public Health Institute. The ideas and opinions expressed herein are those of the author(s), and endorsement by the State of California, Department of Public Health, the NCI, and the Centers for Disease Control and Prevention or their contractors and subcontractors is not intended nor should be inferred. The work of Marquita R. Decker was supported by the NIH Surgical Oncology Training Grant (T32 CA090217).


Marquita R. Decker, Amy Trentham-Dietz, Noelle K. Loconte, Heather B. Neuman, Maureen A. Smith, Rinaa S. Punglia, Caprice C. Greenberg, and Lee G. Wilke have no commercial interests to disclose.


  1. 1.
    Etzioni R, Xia J, Hubbard R, Weiss NS, Gulati R. A reality check for overdiagnosis estimates associated with breast cancer screening. J Natl Cancer Inst. 2014;106(12):dju315.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    van Ravesteyn NT, Miglioretti DL, Stout NK, et al. Tipping the balance of benefits and harms to favor screening mammography starting at age 40 years: a comparative modeling study of risk. Ann Intern Med. 2012;156(9):609-617.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Bleyer A, Welch HG. Effect of three decades of screening mammography on breast-cancer incidence. N Engl J Med. 2012;367(21):1998-2005.CrossRefPubMedGoogle Scholar
  4. 4.
    McCahill LE, Single RM, Aiello Bowles EJ, et al. Variability in re-excision following breast conservation surgery. JAMA. 2012;307(5):467-75.CrossRefPubMedGoogle Scholar
  5. 5.
    Wilke LG, Czechura T, Wang C, Lapin B, et al. Repeat surgery after breast conservation for the treatment of stage 0 to II breast carcinoma: a report from the National Cancer Data Base, 2004-2010. JAMA Surg. 2014;149(12):1296-1305.CrossRefPubMedGoogle Scholar
  6. 6.
    Miller DC, Shah RB, Bruhn A, Madison R; Urologic Diseases in America Project. Trends in the use of gross and frozen section pathological consultations during partial or radical nephrectomy for renal cell carcinoma. J Urol. 2008;179(2):461-467.CrossRefPubMedGoogle Scholar
  7. 7.
    Parvez E, Hodgson N, Cornacchi SD, et al. Survey of American and Canadian general surgeons’ perceptions of margin status and practice patterns for breast conserving surgery. Breast J. 2014;20(5):481-8.CrossRefPubMedGoogle Scholar
  8. 8.
    Esbona K, Li Z, Wilke LG. Intraoperative imprint cytology and frozen section pathology for margin assessment in breast conservation surgery: a systematic review. Ann Surg Oncol. 2012;19(10):3236-45.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Boughey JC, Hieken TJ, Jakub JW, et al. Impact of analysis of frozen-section margin on reoperation rates in women undergoing lumpectomy for breast cancer: evaluation of the National Surgical Quality Improvement Program data. Surgery 2014;156(1):190-197.CrossRefPubMedGoogle Scholar
  10. 10.
    Chagpar A, Yen T, Sahin A, et al. Intra-operative margin assessment reduces reexcision rates in patients with ductal carcinoma in situ treated with breast-conserving surgery. Am J Surg. 2003;186(4):371-377.CrossRefPubMedGoogle Scholar
  11. 11.
    Fleming FJ, Hill AD, McDermott EW, O’Doherty A, O’Higgins NJ, Quinn CM. Intraoperative margin assessment and re-excision rate in breast conserving surgery. Eur J Surg Oncol. 2004;30(3):233-7.CrossRefPubMedGoogle Scholar
  12. 12.
    Jorns JM, Visscher D, Sabel M, Breslin T, Healy P, Daignaut S, et al. Intraoperative frozen section analysis of margins in breast conserving surgery significantly decreases reoperative rates: one-year experience at an ambulatory surgical center. Am J Clin Path. 2012;138(5):657-69.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Sabel MS, Jorns JM, Wu A, Myers J, Newman LA, Breslin TM. Development of an intraoperative pathology consultation service at a free-standing ambulatory surgical center: clinical and economic impact for patients undergoing breast cancer surgery. Am J Surg. 2012;204(1):66-77.CrossRefPubMedGoogle Scholar
  14. 14.
    Cendán JC, Coco D, Copeland EM. Accuracy of intraoperative frozen-section analysis of breast cancer lumpectomy-bed margins. J Am Coll Surg. 2005;201(2):194-8.CrossRefPubMedGoogle Scholar
  15. 15.
    D’Halluin F, Tas P, Rouquette S, et al. Intra-operative touch preparation cytology following lumpectomy for breast cancer: a series of 400 procedures. Breast J. 2009;18(4):248-53.CrossRefGoogle Scholar
  16. 16.
    Correa C, McGale P, Taylor C, et al. Overview of the randomized trials of radiotherapy in ductal carcinoma in situ of the breast. J Natl Cancer Inst Monogr. 2010;2010(41):162-77.CrossRefPubMedGoogle Scholar
  17. 17.
    Monroe AC, Ricketts TC, Savitz LA. Cancer in rural versus urban populations: a review. J Rural Health. 1992;8(3):212-220.CrossRefPubMedGoogle Scholar
  18. 18.
    Ward E, Halpern M, Schrag N, Cokkinides V, et al. Association of insurance with cancer care utilization and outcomes. CA Cancer J Clin. 2008;58(1):9-31.CrossRefPubMedGoogle Scholar
  19. 19.
    Greenberg CC, Lipsitz SR, Hughes ME, et al. Institutional variation in the surgical treatment of breast cancer: a study of the NCCN. Ann Surg. 2011;254(2):339.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Massachusetts General Hospital. Intra-operative digital vs. standard mammography [ identifier NCT01766102]. US National Institutes of Health, Available at:
  21. 21.
    Wilke LG, Brown JQ, Bydlon TM, et al. Rapid noninvasive optical imaging of tissue composition in breast tumor margins. Am J Surg. 2009;198(4):566-74.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Schnabel F, Boolbol SK, Gittleman M, Karni T, Tafra L, Feldman S, et al. A randomized prospective study of lumpectomy margin assessment with use of MarginProbe in patients with nonpalpable breast malignancies. Ann Surg Oncol. 2014;21(5):1589-95.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Surveillance, Epidemiology, and End Results (SEER) Program ( SEER*Stat Database. Incidence source: SEER 18 areas (San Francisco, Connecticut, Detroit, Hawaii, Iowa, New Mexico, Seattle, Utah, Atlanta, San Jose-Monterey, Los Angeles, Alaska Native Registry, Rural Georgia, California excluding SF/SJM/LA, Kentucky, Louisiana, New Jersey and Georgia excluding ATL/RG). National Cancer Institute, DCCPS, Surveillance Research Program, Surveillance Systems Branch, released April 2015.

Copyright information

© Society of Surgical Oncology 2016

Authors and Affiliations

  • Marquita R. Decker
    • 1
    Email author
  • Amy Trentham-Dietz
    • 1
    • 2
  • Noelle K. Loconte
    • 2
  • Heather B. Neuman
    • 3
  • Maureen A. Smith
    • 1
  • Rinaa S. Punglia
    • 4
  • Caprice C. Greenberg
    • 3
  • Lee G. Wilke
    • 3
  1. 1.Department of Population Health SciencesUniversity of Wisconsin School of Medicine and Public HealthMadisonUSA
  2. 2.University of Wisconsin Carbone Cancer CenterMadisonUSA
  3. 3.Department of SurgeryUniversity of Wisconsin School of Medicine and Public HealthMadisonUSA
  4. 4.Dana–Farber Cancer InstituteBostonUSA

Personalised recommendations