Lobar Surgery and Pathological Correlations

  • Giancarlo Dolfin
  • Giovanni Botta


The knowledge of the natural history of the breast carcinoma and its origin, the use of all diagnostic methods, and the good preoperatory control of the suspect zone in the lobe allow us in many cases to carry out a limited operation which is rationally and oncologically correct and to always give the greatest importance to the woman’s image, for her well-being. This chapter points out the need to correlate the radial echographic technique introduced by Michel Teboul and conservative breast surgery.

We always closely connect this methodology to the preoperative ultrasound evaluation and the subsequent reevaluation of the removed lobe with the pathologist.


Ductal echography Breast ultrasound Lobectomy Early breast cancer Anatomopathological examination Presurgical evaluation 



Thanks to doctors Anna Maria Dolfin for providing the images and for the help in writing this chapter; Paolo Tagliabue, fellow surgeon; and Riccardo Arisio, pathologist. Thanks to Silvia Botta for pathological drawings.


  1. 1.
    Veronesi U, Mariani L, Greco M, Saccozzi R, Luini A, Aguilar M, Marubini E. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med. 2002;347(16):1227–32.CrossRefPubMedGoogle Scholar
  2. 2.
    Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch M, Fisher ER, Jeong JH, Wolmark N. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 2002;347(16):1233–41.CrossRefPubMedGoogle Scholar
  3. 3.
    Dolfin G, Tagliabue P, Dolfin AM, Indelicato S. Chirurgia conservativa: cosa possiamo fare per evitare la mutilazione? Riv It Ost Gin. 2007;14:66370.Google Scholar
  4. 4.
    Teboul M. Practical ductal echography. Madrid, Spain: Medgen. S.A; 2004. Google Scholar
  5. 5.
    Tot T. The clinical relevance of the distribution of the lesions in 500 consecutive breast cancer cases documented in large-format histological sections. Cancer. 2007;110:2551–60.CrossRefPubMedGoogle Scholar
  6. 6.
    Durante E. Multimodality imaging and interventional techniques. Ferrara, Italy: IBUS Course Abstracts; 2006.Google Scholar
  7. 7.
    Amoros J, Dolfin G, Teboul M. Atlas de Ecografia de la Mama. Torino: Ananke; 2009.Google Scholar
  8. 8.
    Hunt KK, Sahin AA. Too much, too little, or just right? Tumor margins in women undergoing breast-conserving surgery. J Clin Oncol. 2014;32:14–8.CrossRefGoogle Scholar
  9. 9.
    Amy D, Durante E, Tot T. The lobar approach to breast ultrasound imaging and surgery. J Med Ultrasound. 2015;42(3):331–9.CrossRefGoogle Scholar
  10. 10.
    Tot T. The theory of the sick breast lobe and the possible consequences. Int J Surg Pathol. 2007;15:369.CrossRefPubMedGoogle Scholar
  11. 11.
    Tot T, Gere M, Pekár G, Tarján M, Hofmeyer S, Hellberg D, Lindquist D, Chen TH-H, Yen AM-F, Chiu SY-H, Tabár L. Breast cancer multifocality, disease extent, and survival. Hum Pathol. 2011;42:1761–9.CrossRefPubMedGoogle Scholar
  12. 12.
    Coombs NJ, Boyages J. Multifocal and multicentric breast cancer: does each focus matter? J Clin Oncol. 2005;23:7497–502.CrossRefPubMedGoogle Scholar
  13. 13.
    La Parra RF, De Roos WK, Contant CM, Bavelaar-Croon CD, Barneveld PC, Bosscha K. A prospective validation study of sentinel lymph node biopsy in multicentric breast cancer: SMMaC trial. Eur J Surg Oncol. 2014;40:1250–5.CrossRefGoogle Scholar
  14. 14.
    Donker M, Straver ME, van Tienhoven G, van de Velde CJ, Mansel RE, Litière S, Werutsky G, Duez NJ, Orzalesi L, Bouma WH, van der Mijle H, Nieuwenhuijzen GA, Veltkamp SC, Helen Westenberg A, Rutgers EJ. Comparison of the sentinel node procedure between patients with multifocal and unifocal breast cancer in the EORTC 10981-22023 AMAROS Trial: identification rate and nodal outcome. Eur J Cancer. 2013;49:2093.CrossRefPubMedGoogle Scholar
  15. 15.
    Yerushalmi R, Tyldesley S, Woods R, Kennecke HF, Speers C, Gelmon KA. Is breast-conserving therapy a safe option for patients with tumor multicentricity and multifocality? Ann Oncol. 2012;23:876–81.CrossRefPubMedGoogle Scholar
  16. 16.
    Holland R, Veling SH, Mravunac M, Hendriks JH. Histologic multifocality of Tis, T1-2 breast carcinomas. Implications for clinical trials of breast-conserving surgery. Cancer. 1985;56:979–90.CrossRefPubMedGoogle Scholar
  17. 17.
    Turnbull L, Brown S, Harvey I, Olivier C, Drew P, Napp V, Hanby A, Brown J. Comparative effectiveness of MRI in breast cancer (COMICE) trial: a randomised controlled trial. Lancet. 2010;375:563–71.CrossRefPubMedGoogle Scholar
  18. 18.
    Peters NH, van Esser S, van den Bosch MA, Storm RK, Plaisier PW, van Dalen T, Diepstraten SC, Weits T, Westenend PJ, Stapper G, Fernandez-Gallardo MA, Borel Rinkes IH, van Hillegersberg R, Mali WP, Peeters PH. Preoperative MRI and surgical management in patients with nonpalpable breast cancer: the MONET - randomised controlled trial. Eur J Cancer. 2011;47:879–88627.CrossRefPubMedGoogle Scholar
  19. 19.
    Biesemier KW, Alexander C. Enhancement of mammographic-pathologic correlation utilizing large format histology for malignant breast disease. Semin Breast Dis. 2005;8:152–62.CrossRefGoogle Scholar
  20. 20.
    Tot T. The role of large-format histopathology in assessing subgross morphological prognostic parameters: a single institution report of 1000 consecutive breast cancer cases. Int J Breast Cancer. 2012;2012:395–415.Google Scholar
  21. 21.
    Foschini MP, Flamminio F, Miglio R, et al. The impact of large sections on the study of in situ and invasive duct carcinoma of the breast. Hum Pathol. 2007;38:1736–43.CrossRefPubMedGoogle Scholar
  22. 22.
    Tot T, Pekár G, Hofmeyer S, et al. The distribution of lesions in 1-14-mm invasive breast carcinomas and its relation to metastatic potential. Virchows Arch. 2009;455:109–15.CrossRefPubMedGoogle Scholar
  23. 23.
    Tot T. DCIS, cytokeratins, and the theory of the sick lobe. Virchows Arch. 2005;447:1–8.CrossRefPubMedGoogle Scholar
  24. 24.
    Osen R, et al. Rosen’s breast pathology. 4th ed. Philadelphia: Wolters Kluwer Health; 2015.Google Scholar
  25. 25.
    Lobar AD. Ultrasound of the breast. In: Tot T, editor. Breast cancer. London: Springer; 2011. p. 153–62.Google Scholar
  26. 26.
    Lavoué V, Fritel X, Antoine M, Beltjens F, Bendifallah S, Boisserie-Lacroix M, Boulanger L, Canlorbe G, Catteau-Jonard S, Chabbert-Buffet N, Chamming’s F, Chéreau E, Chopier J, Coutant C, Demetz J, Guilhen N, Fauvet R, Kerdraon O, Laas E, Legendre G, Mathelin C, Nadeau C, Naggara IT, Ngô C, Ouldamer L, Rafii A, Roedlich MN, Seror J, Séror JY, Touboul C, Uzan C, Daraï E, French College of Gynecologists and Obstetricians (CNGOF). Clinical practice guidelines from the French College of Gynecologists and Obstetricians (CNGOF): benign breast tumors - short text. Eur J Obstet Gynecol Reprod Biol. 2016;200:16–23.CrossRefPubMedGoogle Scholar
  27. 27.
    Mitra S, Dey P. Fine-needle aspiration and core biopsy in the diagnosis of breast lesions: a comparison and review of the literature. Cytojournal. 2016;13:18.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Wesoła M, Jeleń M. The diagnostic efficiency of fine needle aspiration biopsy in breast cancers - review. Adv Clin Exp Med. 2013;22(6):887–92.PubMedGoogle Scholar
  29. 29.
    National Breast Cancer Centre. Breast fine needle aspiration cytology and core biopsy: a guide for practice. 2004. This book can also be downloaded from the National Breast Cancer Centre website Scholar
  30. 30.
    Feoli F, Ameye L, Van Eeckhout P, Paesmans M, Marra V, Arisio R. Liquid-based cytology of the breast: pitfalls unrecognized before specific liquid-based cytology training - proposal for a modification of the diagnostic criteria. Acta Cytol. 2013;57(4):369–76.CrossRefPubMedGoogle Scholar
  31. 31.
    Willems SM, van Deurzen CH, van Diest PJ. Diagnosis of breast lesions: fine-needle aspiration cytology or core needle biopsy? A review. J Clin Pathol. 2012;65(4):287–92.CrossRefPubMedGoogle Scholar
  32. 32.
    Nassar A. Core needle biopsy versus fine needle aspiration biopsy in breast--a historical perspective and opportunities in the modern era. Diagn Cytopathol. 2011;39(5):380–8.CrossRefPubMedGoogle Scholar
  33. 33.
    Rageth CJ, O’Flynn EA, Comstock C, Kurtz C, Kubik R, Madjar H, Lepori D, Kampmann G, Mundinger A, Baege A, Decker T, Hosch S, Tausch C, Delaloye JF, Morris E, Varga Z. First International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions). Breast Cancer Res Treat. 2016;159(2):203–13.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Park HL, Hong J. Vacuum-assisted breast biopsy for breast cancer. Gland Surg. 2014;3(2):120–728.PubMedPubMedCentralGoogle Scholar
  35. 35.
    Tot T, Ibarra JA. Examination of specimens from patients with ductal carcinoma in situ of the breast using large-format histology sections. Arch Pathol Lab Med. 2009;133(9):1361.PubMedGoogle Scholar
  36. 36.
    Fisher CS, Mushawah FA, Cyr AE, Gao F, Margenthaler JA. Ultrasound-guided lumpectomy for palpable breast cancers. Ann Surg Oncol. 2011;18:3198–203.CrossRefPubMedGoogle Scholar
  37. 37.
    Luini A, Gatti G, Zurrida S, Caldarella P, Viale G, Rosali dos Santos G, Frasson A. The surgical margin status after breast-conserving surgery: discussion of an open issue. Breast Cancer Res Treat. 2009;113(2):397–402.CrossRefPubMedGoogle Scholar
  38. 38.
    Dolfin G, Chebib A, Amy D, Tagliabue P. Carcinoma mammarie et Chirurgie Conservatrice. 30° Seminare Franco-Syrien d’Imagerie Médicale. Tartous, Syrie; 2008.Google Scholar
  39. 39.
    Volders JH, Haloua MH, Krekel NM, Meijer S, van den Tol PM. Current status of ultrasound-guided surgery in the treatment of breast cancer. World J Clin Oncol. 2016;7(1):44–53.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Krekel N, Zonderhuis B, Muller S, Bril H, van Slooten HJ, de Lange de Klerk E, van den Tol P, Meijer S. Excessive resections in breast-conserving surgery: a retrospective multicentre study. Breast J. 2011;17:602–9.CrossRefPubMedGoogle Scholar
  41. 41.
    Pan H, Wu N, Ding H, Ding Q, Dai J, Ling L, Chen L, Zha X, Liu X, Zhou W, et al. Intraoperative ultrasound guidance is associated with clear lumpectomy margins for breast cancer: a systematic review and meta-analysis. PLoS One. 2013;8:e74028.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Tot T, Tabár L. Mammographic pathologic correlation of ductal carcinoma in situ of the breast using two- and three-dimensional large histologic sections. Semin Breast Dis. 2005;8:144–51.CrossRefGoogle Scholar
  43. 43.
    Tomoka H, Masataka S, Junko I, et al. Impact of intraoperative specimen mammography on margins in breast-conserving surgery. Mol Clin Oncol. 2016;5:269–72.CrossRefGoogle Scholar
  44. 44.
    Chiappa C, Rovera F, Corben AD, Fachinetti A, De Berardinis V, Marchionini V, Rausei S, Boni L, Dionigi G, Dionigi R. Surgical margins in breast conservation. Int J Surg. 2013;11(Suppl 1):S69–72.CrossRefPubMedGoogle Scholar
  45. 45.
    Houssami N, Morrow M. Margins in breast conservation: a clinician’s perspective and what the literature tells us. J Surg Oncol. 2014;110(1):2–7.CrossRefPubMedGoogle Scholar
  46. 46.
    Moehrle M, Breuninger H, Röcken M. A confusing world: what to call histology of three-dimensional tumour margins? J Eur Acad Dermatol Venereol. 2007;21(5):591–5.PubMedGoogle Scholar
  47. 47.
    Dolfin G, et al. The surgical approach to the “sick lobe” in breast cancer: a new era in management. New York: Springer; 2014.Google Scholar
  48. 48.
    Tot T. Subgross morphology, the sick lobe hypothesis, and the success of breast conservation. Int J Breast Cancer 2011;2011: Article ID 634021.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.GynecologistOncologistTorinoItaly
  2. 2.Department of PathologySant’ Anna HospitalTorinoItaly

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