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Digital Breast Tomosynthesis for Intraoperative Margin Assessment during Breast-Conserving Surgery

  • Ko Un Park
  • Henry M. Kuerer
  • Gaiane M. Rauch
  • Jessica W. T. Leung
  • Aysegul A. Sahin
  • Wei Wei
  • Yisheng Li
  • Dalliah M. BlackEmail author
Breast Oncology

Abstract

Background

Intraoperative margin assessment for breast cancer patients undergoing segmental mastectomy (SM) enables identification of positive margins, with immediate excision of additional tissue to obtain negative margins.

Objective

The aim of this study was to determine the ability of digital breast tomosynthesis (DBT) to detect positive margins compared with an institution’s standard extensive processing (SEP).

Methods

SM specimens underwent intraoperative SEP with two-dimensional (2D) imaging of the intact and sliced specimen, with review by a breast radiologist and gross assessment by a breast pathologist. Findings guided the surgeon to excise additional tissue. DBT images of intact specimens were prospectively obtained and retrospectively reviewed by a breast radiologist. A positive margin was defined as tumor at ink.

Results

Ninety-eight patients underwent 99 SMs. With SEP, 14 (14%) SM specimens had 19 positive margins. SEP did not detect 3 of the 19 positive margins, for a sensitivity of 84%, specificity of 78%, positive predictive value (PPV) of 11%, and negative predictive value (NPV) of 99%. Moreover, DBT did not detect 5 of the 19 positive margins, for a sensitivity of 74% (p > 0.05), specificity of 91% (p < 0.05), PPV of 21.5%, and NPV of 99%. With SEP guidance to excise additional tissue, six cases had final positive margins, with SEP not identifying three of these cases and DBT not identifying two. Pathology from the second surgery of these patients showed either no additional malignancy or only focal ductal carcinoma in situ.

Conclusions

DBT is an accurate method for detecting positive margins in breast cancer patients undergoing SM, performing similar to institutional labor-intensive, intraoperative standard processing.

Notes

Acknowledgment

The authors would like to thank Arnold Dahay, Davis Parambil, and Koreene Rockwood, histopathology technicians, for their contribution in processing the specimens for this study.

Disclosure

Wei Wei’s work was generously supported by The Cancer Centre Support Grant from National Institute for Health/National Cancer Institute grant P30CA016672. Ko Un Park, Henry M. Kuerer, Gaiane M. Rauch, Jessica W. T. Leung, Aysegul A. Sahin, Yisheng Li, and Dalliah M. Black have no relevant financial disclosures to declare.

Supplementary material

10434_2019_7226_MOESM1_ESM.pptx (1.8 mb)
Supplementary material 1 (PPTX 1867 kb)

References

  1. 1.
    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 invasive breast cancer. N. Engl. J. Med. 2002;347(16):1233–1241.CrossRefPubMedGoogle Scholar
  2. 2.
    Veronesi U, Cascinelli N, Mariani L, et al. 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):1227–1232.CrossRefPubMedGoogle Scholar
  3. 3.
    Houssami N, Macaskill P, Marinovich ML, 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(18):3219–3232.CrossRefPubMedGoogle Scholar
  4. 4.
    Early Breast Cancer Trialists’ Collaborative Group (EBCTCG), 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 randomised trials. Lancet. 2011;378(9804):1707–16.Google Scholar
  5. 5.
    Morrow M, Abrahamse P, Hofer TP, et al. Trends in reoperation after initial lumpectomy for breast cancer: addressing overtreatment in surgical management. JAMA Oncol. 2017;3:1352–1357.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Reyna C, DeSnyder SM. Intraoperative margin assessment in breast cancer management. Surg. Oncol. Clin. N. Am. 2018;27:155–165.CrossRefPubMedGoogle Scholar
  7. 7.
    Yu J, Elmore LC, Cyr AE, Aft RL, Gillanders WE, Margenthaler JA. Cost analysis of a surgical consensus guideline in breast-conserving surgery. J Am Coll. Surg. 2017;225(2):294–301.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Singer L, Brown E, Lanni T Jr. Margins in breast conserving surgery: The financial cost & potential savings associated with the new margin guidelines. Breast. 2016;28:1–4.CrossRefPubMedGoogle Scholar
  9. 9.
    Jung W, Kang E, Kim SM et al. Factors associated with re-excision after breast-conserving surgery for early-stage breast cancer. J. Breast Cancer 2012;15:412–419.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    St John ER, Al-Khudairi R, Ashrafian H et al. Diagnostic accuracy of intraoperative techniques for margin assessment in breast cancer surgery: a meta-analysis. Ann. Surg. 2017;265:300–310.CrossRefPubMedGoogle Scholar
  11. 11.
    Lei J, Yang P, Zhang L et al. Diagnostic accuracy of digital breast tomosynthesis versus digital mammography for benign and malignant lesions in breasts: a meta-analysis. Eur. Radiol. 2014;24:595–602.CrossRefPubMedGoogle Scholar
  12. 12.
    Eghtedari M, Tsai C, Robles J et al. Tomosynthesis in breast cancer imaging: how does it fit into preoperative evaluation and surveillance? Surg. Oncol. Clin. N. Am. 2018;27:33–49.CrossRefPubMedGoogle Scholar
  13. 13.
    Bernardi D, Macaskill P, Pellegrini M et al. Breast cancer screening with tomosynthesis (3D mammography) with acquired or synthetic 2D mammography compared with 2D mammography alone (STORM-2): a population-based prospective study. Lancet Oncol. 2016;17:1105–1113.CrossRefPubMedGoogle Scholar
  14. 14.
    McDonald ES, Oustimov A, Weinstein SP et al. Effectiveness of digital breast tomosynthesis compared with digital mammography: outcomes analysis from 3 years of breast cancer screening. JAMA Oncol 2016;2:737–743.CrossRefPubMedGoogle Scholar
  15. 15.
    Hodgson R, Heywang-Köbrunner SH, Harvey SC et al. Systematic review of 3D mammography for breast cancer screening. Breast 2016;27:52–61.CrossRefPubMedGoogle Scholar
  16. 16.
    Seo N, Kim HH, Shin HJ et al. Digital breast tomosynthesis versus full-field digital mammography: comparison of the accuracy of lesion measurement and characterization using specimens. Acta Radiologica 2014;55:661–667.CrossRefPubMedGoogle Scholar
  17. 17.
    Urano M, Shiraki N, Kawai T et al. Digital mammography versus digital breast tomosynthesis for detection of breast cancer in the intraoperative specimen during breast-conserving surgery. Breast Cancer 2016;23:706–711.CrossRefPubMedGoogle Scholar
  18. 18.
    Schnitt SJ, Connolly JL. Processing and evaluation of breast excision specimens. A clinically oriented approach. Am. J. Clin. Pathol. 1992;98:125–137.CrossRefPubMedGoogle Scholar
  19. 19.
    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;186:371–377.CrossRefPubMedGoogle Scholar
  20. 20.
    Mukhtar RA, Wong J, Piper M, Zhu Z, Fahrner-Scott K, Mamounas M, et al. Breast conservation and negative margins in invasive Lobular Carcinoma: the impact of oncoplastic surgery and shave margins in 358 patients. Ann Surg Oncol. 2018;25(11):3165–3170.CrossRefPubMedGoogle Scholar
  21. 21.
    Chagpar AB, Killelea BK, Tsangaris TN, Butler M, Stavris K, Li F, et al. A randomized, controlled trial of cavity shave margins in breast cancer. N Engl J Med. 2015;373(6):503–10.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Chagpar AB, Horowitz NR, Killelea BK, Tsangaris T, Longley P, Grizzle S, et al. Economic impact of routine cavity margins versus standard partial mastectomy in breast cancer patients: results of a randomized controlled trial. Ann Surg. 2017;265(1):39–44.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Amer HA, Schmitzberger F, Ingold-Heppner B et al. Digital breast tomosynthesis versus full-field digital mammography—which modality provides more accurate prediction of margin status in specimen radiography? Eur. J. Radiol. 2017;93:258–264.CrossRefPubMedGoogle Scholar
  24. 24.
    Schulz-Wendtland R, Dilbat G, Bani M et al. Full Field Digital Mammography (FFDM) versus CMOS technology versus tomosynthesis (DBT)–which system increases the quality of intraoperative imaging? Geburtshilfe Frauenheilkd. 2012;72(6):532–538.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Cabioglu N, Hunt KK, Sahin AA et al. Role for intraoperative margin assessment in patients undergoing breast-conserving surgery. Ann. Surg. Oncol. 2007;14:1458–1471.CrossRefPubMedGoogle Scholar
  26. 26.
    Carter SA, Lyons GR, Kuerer HM, Bassett RL Jr, Oates S, Thompson A, et al. Operative and oncologic outcomes in 9861 patients with operable breast cancer: single-institution analysis of breast conservation with oncoplastic reconstruction. Ann. Surg. Oncol. 2016;23(10):3190–8.CrossRefPubMedGoogle Scholar
  27. 27.
    Tevis SE, Neuman HB, Mittendorf EA, Kuerer HM, Bedrosian I, DeSnyder SM, et al. Multidisciplinary intraoperative assessment of breast specimens reduces number of positive margins. Ann. Surg. Oncol. 2018;25(10):2932–2938.CrossRefPubMedGoogle Scholar

Copyright information

© Society of Surgical Oncology 2019

Authors and Affiliations

  • Ko Un Park
    • 1
    • 6
  • Henry M. Kuerer
    • 1
  • Gaiane M. Rauch
    • 2
  • Jessica W. T. Leung
    • 2
  • Aysegul A. Sahin
    • 3
  • Wei Wei
    • 4
    • 5
  • Yisheng Li
    • 4
  • Dalliah M. Black
    • 1
    Email author
  1. 1.Department of Breast Surgical OncologyUniversity of Texas MD Anderson Cancer CenterHoustonUSA
  2. 2.Department of Diagnostic RadiologyUniversity of Texas MD Anderson Cancer CenterHoustonUSA
  3. 3.Department of PathologyUniversity of Texas MD Anderson Cancer CenterHoustonUSA
  4. 4.Department of BiostatisticsUniversity of Texas MD Anderson Cancer CenterHoustonUSA
  5. 5.Taussig Cancer Institute, The Cleveland ClinicClevelandUSA
  6. 6.Department of Surgery, Division of Surgical OncologyThe Ohio State UniversityColumbusUSA

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