Abstract
Background
Various intraoperative margin assessment techniques have been shown to improve margin status in breast-conserving surgery (BCS) for cancer. Our study sought to evaluate multiple margin assessment techniques on a population level and determine their effects on margin status.
Methods
Patients undergoing wire-localized BCS for invasive cancer in Alberta, Canada, were assessed using a prospectively entered database of patient and tumor characteristics. Margin status was obtained from chart review. Four margin assessment techniques were studied: specimen mammography (SM), intraoperative ultrasound (US), gross assessment by pathologist (GP), and frozen section analysis (FS). Multivariable logistic regression adjusting for confounders was used to assess effect of any technique on margin status, with secondary analysis evaluating effects of individual techniques.
Results
Margin assessment was performed in 1165 of 1649 patients (71 %). The overall positive margin rate was 20.8 %. Adjusting for confounders, we found no difference in the odds of a positive margin with any margin assessment technique versus wire localization alone (OR 0.79, p = 0.22, 95 % CI 0.54–1.16). Individually, both GP and FS reduced the risk of a positive margin (GP–OR 0.56, p = 0.002, 95 % CI 0.39–0.81; FS–OR 0.43, p = 0.046, 95 % CI 0.19–0.98), whereas SM and US showed no effect (SM–OR 1.23, p = 0.29, 95 % CI 0.84–1.81; US–OR 1.09, p = 0.83, 95 % CI 0.50–2.37).
Conclusions
Use of any margin assessment technique did not improve margin status compared to wire localization alone. Gross assessment by pathologist and frozen section analysis improved margin status compared to imaging-alone techniques. Further exploration is required to refine optimal margin assessment methods.
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References
Darby S, McGale P, Correa C, et al. Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomized trials. Lancet. 2011;378:1707–16.
Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of breast cancer. N Engl J Med. 2002;347:1233–41.
Van Dongen JA, Voogd AC, Fentiman IS, et al. Long-term results of a randomized trial comparing breast-conserving therapy with mastectomy: European Organization for Research and Treatment of Cancer 10801 trial. J Natl Cancer Inst. 2000;92:1143–50.
Singletary SE. Surgical margins in patients with early-stage breast cancer treated with breast conservation therapy. Am J Surg. 2002;184:383–93.
Houssami N, Macaskill P, Marinovich ML, Dixon JM, Irwig L, Brennan ME, et al. Meta-analysis of the impact of surgical margins on local recurrence in women with early-stage invasive breast cancer treated with breast-conserving therapy. Eur J Cancer. 2010;46:3219–32.
Morrow M, Strom EA, Bassett LW, et al. Standard for breast conservation therapy in the management of invasive breast carcinoma. CA Cancer J Clin. 2002;52:277–300.
Park CC, Mitsumori M, Nixon A, et al. Outcome at 8 years after breast-conserving surgery and radiation therapy for invasive breast cancer: influence of margin status and systemic therapy on local recurrence. J Clin Oncol. 2000;18:1668–75.
Meric F, Mirza NQ, Vlastos G, et al. Positive surgical margins and ipsilateral breast tumor recurrence predict disease-specific survival after breast-conserving therapy. Cancer. 2003;97:926.
Skinner KA, Silberman H, Sposto R, Silverstein MJ. Palpable breast cancers are inherently different from nonpalpable breast cancers. Ann Surg Oncol. 2001;8:705–10.
Lovrics PJ, Cornacchi SD, Farrokhyar F, Garnett A, Chen V, Franic S, et al. The relationship between surgical factors and margin status after breast-conservation surgery for early stage breast cancer. Am J Surg. 2009;197:740–6.
Atkins J, Al Mushawah F, Appleton CM, et al. Positive margin rates following breast-conserving surgery for stage I–III breast cancer: palpable versus nonpalpable tumours. J Surg Res. 2012;177:109–15.
Dillon MF, Hill AD, Quinn CM, McDermott EW, O’Higgins N. A pathologic assessment of adequate margin status in breast-conserving therapy. Ann Surg Oncol. 2006;13:333–9.
Jacobs L. Positive margins: the challenge continues for breast surgeons. Ann Surg Oncol. 2008;15:1271–2.
Tafra L, Fine R, Whitworth P, et al. Prospective randomized study comparing cryo-assisted and needle-wire localization of ultrasound-visible breast tumours. Am J Surg. 2006;192:462–70.
Krekel NMA, Zonderhuis BM, Stockmann HBAC, et al. A comparison of three methods of nonpalpable breast cancer excision. Eur J Surg Oncol. 2011;37:109–15.
Haid A, Knauer M, Dunzinger S, et al. Intra-operative sonography: a valuable aid during breast-conserving surgery for occult breast cancer. Ann Surg Oncol. 2007;14:3090–101.
Moore MA, Whitney LA, Cerilli L, Imbrie JZ, Bunch M, Simpson VB, et al. Intraoperative ultrasound is associated with clear lumpectomy margins for palpable infiltrating ductal breast cancer. Ann Surg. 2001;233:761–8.
Rahusen FD, Bremers AJA, Fabry HFJ, Taets van Amerongen AHM, Boom RPA, Meijer S. Ultrasound-guided lumpectomy of nonpalpable breast cancer versus wire-guided resection: a randomized clinical trial. Ann Surg Oncol. 2002;9:994–8.
Chagpar A, Yen T, Sahin A, et al. Intraoperative margin assessment reduces reexcision rates in patients with ductal carcinoma in situ treated with breast-conserving surgery. Am J Surg. 2003;186:371–7.
Fleming FJ, Hill ADK, McDermott EW, O’Doherty A, O’Higgens NJ, Quinn CM. Intraoperative margin assessment and re-excision rate in breast conserving surgery. Eur J Surg Oncol. 2004;30:233–7.
Esbona K, Li Z, Wilke L. intraoperative imprint cytology and frozen section pathology for margin assessment in breast conservation surgery: a systematic review. Ann Surg Oncol. 2012;19:3236–45.
Mendonca Munhoz A, Montag E, Arruda E, et al. Immediate reconstruction following breast-conserving surgery: management of the positive surgical margins and influence on secondary reconstruction. Breast. 2009;18:47–54.
Cendan JC, Coco D, Copeland EM III. Accuracy of intraoperative frozen-section analysis of breast cancer lumpectomy-bed margins. J Am Coll Surg. 2005;201:194–8.
Olsha O, Shemesh D, Carmon M, Sibirsky O, Dalo RA, Rivkin L, et al. Resection margins in ultrasound-guided breast-conserving surgery. Ann Surg Oncol. 2011;18:447–52.
Harness JK, Guiliano AE, Pockaj BA, Downs-Kelly E. Margins: a status report from the annual meeting of the American Society of Breast Surgeons. Ann Surg Oncol. 2014;21:3192–7.
Parvez E, Hodgson N, Cornacchi SD, et al. Survey of American and Canadian Surgeons’ perceptions of margin status and practice patterns for breast conserving surgery. Breast J 2014;20:481–8.
Olson TP, Harter J, Munoz A, Mahvi DM, Breslin TM. Frozen section analysis for intraoperative margin assessment during breast-conserving surgery results in low rates of re-excision and local recurrence. Ann Surg Oncol. 2007;14:2953–60.
Park S, Park HS, Kim SI, Koo JS, Park BW, Lee KS. The impact of a focally positive resection margin on the local control in patients treated with breast-conserving therapy. Jpn J Clin Oncol. 2011;41:600–8.
Fukamachi K, Ishida T, Usami S, Takeda M, Watanabe M, Sasano H, et al. Total-circumference intraoperative frozen section analysis reduces margin-positive rate in breast-conservation surgery. Jpn J Clin Oncol. 2010;40:513–20.
Balch GC, Mithani SK, Simpson JF, Kelley MC. Accuracy of intraoperative gross examination of surgical margin status in women undergoing partial mastectomy for breast malignancy. Am Surg. 2005;71:22–7.
Bolger JC, Solon JG, Khan SA, Hill ADK, Power CP. A comparison of intra-operative margin assessment techniques in breast-conserving surgery: a standardised approach reduces the likelihood of residual disease without increasing operative time. Breast Cancer. 2015;22:262–8.
Kaufman CS, Jacobsen L, Bachman BA, et al. Intraoperative digital specimen mammography: rapid, accurate results expedite surgery. Ann Surg Oncol. 2007;14:1478–85.
Britton PD, Sonoda LI, Yamamoto AK, Koo B, Soh E, Goud A. Breast surgical specimen radiographs: How reliable are they? Eur J Radiol. 2011;79:245–9.
Layfield DM, May DJ, Cutress RI, Richardson C, Agrawal A, Wise M, et al. The effect of introducing an in-theatre intra-operative specimen radiography (IOSR) system on the management of palpable breast cancer within a single unit. Breast. 2012;21:459–63.
Bathla L, Harris A, Davey M, Sharma P, Silva E. High resolution intra-operative two-dimensional specimen mammography and its impact on second operation for re-excision of positive margins at final pathology after breast conservation surgery. Am J Surg. 2011;202:387–94.
Ciccarelli G, Di Virgilio MR, Menna S, et al. Radiography of the surgical specimen in early stage breast lesions: diagnostic reliability in the analysis of the resection margins. Radiol Med. 2007;112:366–76.
Weber WP, Engelberger S, Viehl CT, et al. Accuracy of frozen section analysis versus specimen radiography during breast-conserving surgery for nonpalpable lesions. World J Surg. 2008;32:2599–606.
Mesurolle B, El-Khoury M, Hori D, Phancao JP, Kary S, Kao E, et al. Sonography of postexcision specimens of nonpalpable breast lesions: value, limitations and description of a method. AJR Am J Roentgenol. 2006;186:1014–24.
Londero V, Zuiani C, Panozzo M, Linda A, Girometti R, Bazzocchi M. Surgical specimen ultrasound: Is it able to predict the status of resection margins after breast-conserving surgery? Breast. 2010;19:532–7.
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Laws, A., Brar, M.S., Bouchard-Fortier, A. et al. Intraoperative Margin Assessment in Wire-Localized Breast-Conserving Surgery for Invasive Cancer: A Population-Level Comparison of Techniques. Ann Surg Oncol 23, 3290–3296 (2016). https://doi.org/10.1245/s10434-016-5401-2
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DOI: https://doi.org/10.1245/s10434-016-5401-2