BREAST SURGERY ANZJSurg.com
Predictors of re-excision in wire-guided wide local excision for early breast cancer: a Western Australian multi-centre experience Helen Ballal,* Donna B. Taylor,†‡ Anita G. Bourke,§ Bruce Latham¶ and Christobel M. Saunders‡ *Breast Centre, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia †Department of Radiology, Royal Perth Hospital, Perth, Western Australia, Australia ‡School of Surgery, University of Western Australia, Perth, Western Australia, Australia §Department of Radiology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia and ¶Department of Pathology, Royal Perth Hospital, Perth, Western Australia, Australia
MeSH Key words breast neoplasm/pathology, breast neoplasm/surgery, female, human, reoperation. Correspondence Dr Helen Ballal, General Surgery, Breast Centre, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA 6009, Australia. Email: [email protected] Accepted for publication 19 February 2015. H. Ballal MBBS, MRCS; D. B. Taylor MBBS, FRANZCR, FRCP (C); A. G. Bourke MBBCh, FFR (R.C.S.I.), FRANZCR, FAANMS; B. Latham BMedSci, MBBS, FRCPA; C. M. Saunders BS, FRCS, FRCS (Gen Surg), FRACS. doi: 10.1111/ans.13067
Abstract Background: A significant proportion of breast cancers present as impalpable lesions requiring radiological guidance prior to surgical excision, commonly by hook-wire placement. Complete lesion excision is an essential part of treatment, and re-excision may be needed to ensure this and minimize local recurrence. We explore a 1-year audit of re-excision of hook-wire-guided excisions in two large public breast units in Western Australia and define factors associated with the requirement for re-excision. Methods: A retrospective review of wire-localized wide local excisions for early breast cancer in 2009 at two tertiary breast centres in Western Australia. Results: Of 148 localized lesions, 44 (30%) underwent re-excision. The only significant preoperative finding was the location of tumour in the breast. The intra-operative specimen radiograph provided useful information that influenced re-excision. Smaller (≤5 mm) and larger (>20 mm) tumours on final pathological size were more likely to undergo re-excision as well as a larger difference in actual size to predicted size. The presence of ductal carcinoma in situ (DCIS) increased re-operation, as did multifocality. Conclusion: This study highlights factors that should make the surgeon more cautious for re-excision. Suspicion of DCIS, especially at the periphery of tumours, and a central tumour location increase risk. Lesion localization techniques play an important role in minimizing risk while maintaining cosmesis.
Introduction Following the results of randomized trials in the 1980s, breast-conserving surgery has become the most common surgical management of early breast cancer.1,2 Mammographic screening programmes have resulted in increasing detection of impalpable invasive and in situ disease requiring image guidance to aid surgical excision.3–5 In Australia, this is most often achieved by the use of hook-wire localization (HWL): 90% of breast surgeons in Australia and New Zealand were using HWL in a recent survey (unpublished data). The presence of malignant cells at or close to the resection margin is associated with increased rates of local recurrence.6–9 To minimize this, patients often undergo a second or third operation to achieve clear surgical margins.10 Re-excision rates worldwide are reported to be between 17% and 68%.11–13 This wide variation reflects the heterogeneity of studies, many of which include diagnostic open biopANZ J Surg 85 (2015) 540–545
sies. Comparison of results is difficult because of lack of consensus as to the definition of adequate surgical margins and considerable variation in surgical and pathological handling of specimens. Identifying factors that can potentially reduce re-excision rates is important to decrease potential complications of a second operation and avoid delays in starting adjuvant therapy. Re-excision may increase surgical costs and patient expense, and may increase patient anxiety. Less favourable cosmetic outcomes and increased mastectomy rates may result.14 Studies also suggest re-operation is associated with increased rates of local and distant recurrence even when adequate margins are achieved.10,15,16 Previous studies have shown radiological factors that increase re-excision rates including suspicious micro-calcifications on mammography and the use of stereotactic guidance for localization.17,18 Tumour factors that have been shown to increase re-excision rates include patient age, presence of ductal carcinoma in situ (DCIS), large size of invasive or in situ component, high grade, lobular © 2015 Royal Australasian College of Surgeons
Re-excision in localized breast cancers
phenotype and multifocality.10,12,19–21 Surprisingly, a recently published study of all National Health Service centres in England found the re-operation rate was not associated with volume of activity.22 In 2009, BreastScreen WA performed 91 319 screening mammograms and identified 579 cancers. Sixty-seven percent of these women opted for breast-conserving surgery.23 A significant proportion of these cancers are impalpable requiring localization to guide lumpectomy. While some patients elect to have surgery privately, we report on the subset treated at two tertiary public hospitals in Western Australia. Although there is a general lack of worldwide consensus as to what constitutes adequate pathological margins,24–26 definitions for minimum acceptable radial margins for invasive cancer (5 mm) and in situ disease (10 mm) were in use at both our centres at the time. Neither centre performed frozen section nor touch imprint preparations to provide immediate intra-operative margin assessment. Intra-operative specimen radiography was performed for all cases, with addition of specimen ultrasound for some radiographically occult lesions. A small number of cases underwent re-excision of margins (cavity shave) at the time of the original surgery based on surgeon’s palpation and/or concerns raised on the immediate specimen radiograph. Post-operative management decisions were made following multidisciplinary review of each case. Our aim was to determine the re-excision rate as a separate procedure in this cohort and identify factors influencing it.
Methods Approval was gained from our Institutional Ethics Committees to conduct an audit of all consecutive patients who had undergone wire-guided wide local excision for breast cancer in 2009 using hospital databases. Patients were excluded if they did not have a preoperative malignant diagnosis, had undergone neo-adjuvant therapy, if another localization technique was used in conjunction with the wire (e.g. radioactive labelling) or if therapeutic mammoplasty had been performed. Patients with pure lobular carcinoma in situ were also excluded. Digital specimen radiographs were performed in the Breast Clinic with images immediately available for review by the surgeon. Specimen ultrasound was performed in some cases for radiographically occult lesions. A verbal report was telephoned to theatre in most cases. The pre- and intra-operative breast imaging studies for each patient were reviewed by one of three senior breast radiologists (DT, AB and DD). Preoperative and final pathology reports were reviewed, with case reassessment by the study pathologist for clarification as necessary. Data collected included age of patient, referral source, clinical findings, number of visible lesions, location in breast, distance from nipple, maximum size on imaging, sonographic and mammographic findings, lesion type on core biopsy, Breast Imaging – Reporting and Data System (BIRADS, American College of Radiology, Reston, VA, USA) breast density score, localization method, wire position and specimen radiograph measurements. The optimal resection volume, defined as the spherical tumour volume with an added © 2015 Royal Australasian College of Surgeons
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1.0-cm margin, and the total resection volume (TRV), defined as the corresponding ellipsoid, were calculated as described by Krekel et al.27 By dividing the TRV by the optimal resection volume, a calculated resection ratio (CRR) was determined to indicate the excess tissue resection. The mammographic images were used to determine the distances from the centre of the lesion to the border of the specimen, which is an indication of the amount of tissue excised, and the difference between the maximum and minimum distances, which indicates concentricity.28 The post-operative histopathological findings (tumour type, presence of DCIS, multifocality, grade, size and radial margin) and whether extra tissue was submitted at the time of original surgery was also evaluated. Satellite lesions were defined as an area of malignancy separate to the main tumour but within 10 mm and were classified as multifocal for the purpose of analysis. Where final pathological radial margins were outside of the units’ acceptance of clearance but no re-excision was performed, the case notes were reviewed. Data were collected in an Access 2007 database and statistical analysis was conducted using NCSS (2007, NCSS, LLC, Kaysville, UT, USA) software. Proportions were compared using chi-square test and medians using Mann–Whitney U-test. A P-value of 20.1 0–5 5.1–10 10.1–20 >20.1 Unassessable No Yes 0–5 5.1–10 10.1–20 >20.1 Unassessable DCIS Invasive Both Unassessable
4 32 65 14 12 18 22 29 24 98 50 69 32 29 16 2 51 51 24 22
4 (100) 6 (19) 15 (23) 8 (57) 4 (33) 4 (22) 5 (23) 17 (59) 5 (21) 23 (23) 21 (42) 10 (14) 11 (34) 10 (34) 12 (75) 1 (50) 24 (47) 15 (29) 3 (13) 2 (9)
0.00 — — — 0.02 — — — — 0.02 — 0.00 — — — — 0.01 — — —
DCIS, ductal carcinoma in situ.
The strengths of our study are that we are one of only a few groups who have examined an entirely wire-localized cohort and included only those with a definitive malignant preoperative diagnosis. Both the study sites are tertiary referral centres and manage the majority of publicly treated breast cancers in Western Australia. Our median CRR for HWL of 1.98 is in keeping with other published data.27 The median concentricity score of 27 in combination with the low CRR indicates that unnecessary tissue excision was kept to a minimum. Although separate MDMs are held at each site, there is a uniform definition for acceptable margins and an agreed re-excision policy. Both the size of histological margins and the reasons why cases that did not meet our acceptable margin criteria did not undergo re-excision have been evaluated. The specimen radiography data suggest that a larger final histopathological margin is associated with a higher incidence of re-excision. However, those with close margins are more likely to have had extra tissue taken at the time of surgery. This may have been due to identification of a close margin on specimen imaging; however, this could not be reliably assessed in this retrospective audit as it is not always clear from the operation notes whether the re-excision was influenced by the specimen imaging findings. Although there is a general lack of consensus regarding ‘adequate’ margins there have been recent attempts to quantify this. It is important to note that while a margin of 2 mm improves this if the patient is given whole breast radiotherapy.9 The minimum acceptable radial margin for invasive and in situ malignancy remains controversial in Australia and New Zealand. The Association of Breast Surgeons in the UK recommends that breast centres develop their own local protocols for re-operation.32 There are no current Australian guidelines. Further research is needed into developing tools that can help reduce unnecessary re-operations. Removal of larger volumes of tissue to try and reduce the chance of inadequate margins may © 2015 Royal Australasian College of Surgeons
compromise cosmetic results, although the use of level 1 and 2 oncoplastic techniques allows increased volumes of tissue to be removed with proven low recurrence rates.33 Notably, the literature suggests there is no association between volume taken and re-operation rates or larger margins and decreased local recurrence.9 In our audit, 16 patients (11%) had over 10 mm more disease on final pathology than expected and this was a significant predictor for re-excision. Conventional preoperative imaging techniques (mammography and ultrasound) are unable to identify the full extent of all types of malignancy, particularly non-calcified DCIS.34 This limitation makes it difficult to circumvent the need for re-excision in all cases, leading us to suggest that a re-excision rate of 11% could be justified as a current benchmark for standards in breast-conserving surgery.35 The role of preoperative magnetic resonance imaging (MRI) in guiding breast surgery remains controversial,36 although a recently published randomized multicentre study has shown that in young women, preoperative MRI significantly reduced the re-operation rate without increasing the number of overall mastectomies.37 MRI findings that could alter surgical management should be further evaluated with percutaneous biopsy to avoid the risk of over-treatment.38 Where there is MRI biopsy-proven malignant disease that is occult on conventional imaging, biopsy markers inserted at the time of the MRI-guided biopsy can be subsequently targeted for insertion of bracketing hook-wires using ultrasound or mammography. Although there is no published trial evaluating the efficacy of preoperative bracketing of malignant lesions confirmed only on MRI guided biopsy, in improving margin clearance, this approach could potentially reduce re-excision rates. Translation of preoperative MRI findings (where the patient’s breast is in the prone position) to their corresponding location in the supine patient position during surgery is challenging, and this may help explain why it has been difficult to show preoperative MRI can reduce re-excision rates.39 Recent studies using co-registration and
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projection techniques to help address this issue have shown promising results.40,41 Localization methods that give three-dimensional real-time feedback during surgery such as intra-operative ultrasound (IOUS) and radio-guided techniques (injection of radioisotope (ROLL) and radio-guided occult lesion localisation using iodine-125 seed(s) (ROLLIS)) have been shown to reduce re-excision rates.42,43 Unlike ROLLIS (which can be used for almost all lesions), the use of IOUS is restricted to lesions that are sonographically visible. This is an important limitation, given that DCIS lesions are often occult on ultrasound. Specimen imaging techniques that improve identification of involved or close tumour margins at the time of initial surgery can help direct immediate intra-operative re-excision, potentially reducing the need for second surgery. Ultra-sound and tomosynthesis enable assessment of macroscopic margins in three dimensions44,45 and rapidly developing techniques such as near infrared fluorescence optical imaging and optical coherence tomography may allow microscopic identification of involved or close tumour margins.46
Conclusion Preoperative factors such as centrally located tumours and suspicion of DCIS, particularly at the lesion periphery, increase the risk of positive margins and should make the surgeon more cautious when performing surgery. Lesion localization techniques (such as ROLLIS and IOUS) that give the surgeon real-time three-dimensional feedback have the potential to reduce re-excision rates and optimize cosmetic outcome. This audit forms the baseline for a large Australasian randomized controlled trial to evaluate whether the use of ROLLIS for preoperative localization of impalpable breast cancers can reduce re-excision rates compared with conventional HWL (ACTRN12613000655741).
Acknowledgements The authors would like to thank Ms Jill Tinning, Royal Perth Hospital Breast Centre; Dr Paul Riley, Department of Radiology, Sir Charles Gairdner Hospital; Dr John Bourke, Department of Medicine, Sir Charles Gairdner Hospital; Dr Deepthi Dissanayake, Department of Radiology, Royal Perth Hospital; and Ms Jan Tresham, BSWA.
References 1. Fisher B, Bauer M, Margolese R et al. Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N. Engl. J. Med. 1985; 312: 665–73. 2. 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: 1233–41. 3. Blanks RG, Moss SM, McGahan CE, Quinn MJ, Babb PJ. Effect of NHS breast screening programme on mortality from breast cancer in England and Wales, 1990–8: comparison of observed with predicted mortality. BMJ 2000; 321: 665–9.
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35. Kuhl CK, Schrading S, Bieling HB et al. MRI for diagnosis of pure ductal carcinoma in situ: a prospective observational study. Lancet 2007; 370: 485–92. 36. Solin LJ. Counterview: pre-operative breast MRI (magnetic resonance imaging) is not recommended for all patients with newly diagnosed breast cancer. Breast 2010; 19: 7–9. 37. Gonzalez V, Sandelin K, Karlsson A et al. Preoperative MRI of the breast (POMB) influences primary treatment in breast cancer: a prospective, randomized, multicenter study. World J. Surg. 2014; 38: 1685–93. 38. Mann RM, Kuhl CK, Kinkel K, Boetes C. Breast MRI: guidelines from the European Society of Breast Imaging. Eur. Radiol. 2008; 18: 1307– 18. 39. Sardanelli F. Additional findings at preoperative MRI: a simple golden rule for a complex problem? Breast Cancer Res. Treat. 2010; 124: 717–21. 40. Sakakibara M, Nagashima T, Sangai T et al. Breast-conserving surgery using projection and reproduction techniques of surgical-position breast MRI in patients with ductal carcinoma in situ of the breast. J. Am. Coll. Surg. 2008; 207: 62–8. 41. Alderliesten T, Loo C, Paape A et al. On the feasibility of MRI-guided navigation to demarcate breast cancer for breast-conserving surgery. Med. Phys. 2010; 37: 2617–26. 42. Postma EL, Witkamp AJ, van den Bosch MA, Verkooijen HM, van Hillegersberg R. Localization of nonpalpable breast lesions. Expert Rev. Anticancer Ther. 2011; 11: 1295–302. 43. Dua SM, Gray RJ, Keshtgar M. Strategies for localisation of impalpable breast lesions. Breast 2011; 20: 246–53. 44. Olsha O, Shemesh D, Carmon M et al. Resection margins in ultrasoundguided breast-conserving surgery. Ann. Surg. Oncol. 2011; 18: 447–52. 45. Schulz-Wendtland R, Dilbat G, Bani MR et al. Use of tomosynthesis in intraoperative digital specimen radiography – is a reduction of breast re-excision rates possible? Geburtshilfe Frauenheilkd 2011; 71: 1080–4. 46. Curatolo A, McLaughlin RA, Quirk BC et al. Ultrasound-guided optical coherence tomography needle probe for the assessment of breast cancer tumor margins. AJR Am. J. Roentgenol. 2012; 199: W520–2.
Predictors of re-excision in wire-guided wide local excision for early breast cancer: a Western Australian multi-centre experience Helen Ballal,* Donna B. Taylor,†‡ Anita G. Bourke,§ Bruce Latham¶ and Christobel M. Saunders‡ *Breast Centre, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia †Department of Radiology, Royal Perth Hospital, Perth, Western Australia, Australia ‡School of Surgery, University of Western Australia, Perth, Western Australia, Australia §Department of Radiology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia and ¶Department of Pathology, Royal Perth Hospital, Perth, Western Australia, Australia
MeSH Key words breast neoplasm/pathology, breast neoplasm/surgery, female, human, reoperation. Correspondence Dr Helen Ballal, General Surgery, Breast Centre, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA 6009, Australia. Email: [email protected] Accepted for publication 19 February 2015. H. Ballal MBBS, MRCS; D. B. Taylor MBBS, FRANZCR, FRCP (C); A. G. Bourke MBBCh, FFR (R.C.S.I.), FRANZCR, FAANMS; B. Latham BMedSci, MBBS, FRCPA; C. M. Saunders BS, FRCS, FRCS (Gen Surg), FRACS. doi: 10.1111/ans.13067
Abstract Background: A significant proportion of breast cancers present as impalpable lesions requiring radiological guidance prior to surgical excision, commonly by hook-wire placement. Complete lesion excision is an essential part of treatment, and re-excision may be needed to ensure this and minimize local recurrence. We explore a 1-year audit of re-excision of hook-wire-guided excisions in two large public breast units in Western Australia and define factors associated with the requirement for re-excision. Methods: A retrospective review of wire-localized wide local excisions for early breast cancer in 2009 at two tertiary breast centres in Western Australia. Results: Of 148 localized lesions, 44 (30%) underwent re-excision. The only significant preoperative finding was the location of tumour in the breast. The intra-operative specimen radiograph provided useful information that influenced re-excision. Smaller (≤5 mm) and larger (>20 mm) tumours on final pathological size were more likely to undergo re-excision as well as a larger difference in actual size to predicted size. The presence of ductal carcinoma in situ (DCIS) increased re-operation, as did multifocality. Conclusion: This study highlights factors that should make the surgeon more cautious for re-excision. Suspicion of DCIS, especially at the periphery of tumours, and a central tumour location increase risk. Lesion localization techniques play an important role in minimizing risk while maintaining cosmesis.
Introduction Following the results of randomized trials in the 1980s, breast-conserving surgery has become the most common surgical management of early breast cancer.1,2 Mammographic screening programmes have resulted in increasing detection of impalpable invasive and in situ disease requiring image guidance to aid surgical excision.3–5 In Australia, this is most often achieved by the use of hook-wire localization (HWL): 90% of breast surgeons in Australia and New Zealand were using HWL in a recent survey (unpublished data). The presence of malignant cells at or close to the resection margin is associated with increased rates of local recurrence.6–9 To minimize this, patients often undergo a second or third operation to achieve clear surgical margins.10 Re-excision rates worldwide are reported to be between 17% and 68%.11–13 This wide variation reflects the heterogeneity of studies, many of which include diagnostic open biopANZ J Surg 85 (2015) 540–545
sies. Comparison of results is difficult because of lack of consensus as to the definition of adequate surgical margins and considerable variation in surgical and pathological handling of specimens. Identifying factors that can potentially reduce re-excision rates is important to decrease potential complications of a second operation and avoid delays in starting adjuvant therapy. Re-excision may increase surgical costs and patient expense, and may increase patient anxiety. Less favourable cosmetic outcomes and increased mastectomy rates may result.14 Studies also suggest re-operation is associated with increased rates of local and distant recurrence even when adequate margins are achieved.10,15,16 Previous studies have shown radiological factors that increase re-excision rates including suspicious micro-calcifications on mammography and the use of stereotactic guidance for localization.17,18 Tumour factors that have been shown to increase re-excision rates include patient age, presence of ductal carcinoma in situ (DCIS), large size of invasive or in situ component, high grade, lobular © 2015 Royal Australasian College of Surgeons
Re-excision in localized breast cancers
phenotype and multifocality.10,12,19–21 Surprisingly, a recently published study of all National Health Service centres in England found the re-operation rate was not associated with volume of activity.22 In 2009, BreastScreen WA performed 91 319 screening mammograms and identified 579 cancers. Sixty-seven percent of these women opted for breast-conserving surgery.23 A significant proportion of these cancers are impalpable requiring localization to guide lumpectomy. While some patients elect to have surgery privately, we report on the subset treated at two tertiary public hospitals in Western Australia. Although there is a general lack of worldwide consensus as to what constitutes adequate pathological margins,24–26 definitions for minimum acceptable radial margins for invasive cancer (5 mm) and in situ disease (10 mm) were in use at both our centres at the time. Neither centre performed frozen section nor touch imprint preparations to provide immediate intra-operative margin assessment. Intra-operative specimen radiography was performed for all cases, with addition of specimen ultrasound for some radiographically occult lesions. A small number of cases underwent re-excision of margins (cavity shave) at the time of the original surgery based on surgeon’s palpation and/or concerns raised on the immediate specimen radiograph. Post-operative management decisions were made following multidisciplinary review of each case. Our aim was to determine the re-excision rate as a separate procedure in this cohort and identify factors influencing it.
Methods Approval was gained from our Institutional Ethics Committees to conduct an audit of all consecutive patients who had undergone wire-guided wide local excision for breast cancer in 2009 using hospital databases. Patients were excluded if they did not have a preoperative malignant diagnosis, had undergone neo-adjuvant therapy, if another localization technique was used in conjunction with the wire (e.g. radioactive labelling) or if therapeutic mammoplasty had been performed. Patients with pure lobular carcinoma in situ were also excluded. Digital specimen radiographs were performed in the Breast Clinic with images immediately available for review by the surgeon. Specimen ultrasound was performed in some cases for radiographically occult lesions. A verbal report was telephoned to theatre in most cases. The pre- and intra-operative breast imaging studies for each patient were reviewed by one of three senior breast radiologists (DT, AB and DD). Preoperative and final pathology reports were reviewed, with case reassessment by the study pathologist for clarification as necessary. Data collected included age of patient, referral source, clinical findings, number of visible lesions, location in breast, distance from nipple, maximum size on imaging, sonographic and mammographic findings, lesion type on core biopsy, Breast Imaging – Reporting and Data System (BIRADS, American College of Radiology, Reston, VA, USA) breast density score, localization method, wire position and specimen radiograph measurements. The optimal resection volume, defined as the spherical tumour volume with an added © 2015 Royal Australasian College of Surgeons
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1.0-cm margin, and the total resection volume (TRV), defined as the corresponding ellipsoid, were calculated as described by Krekel et al.27 By dividing the TRV by the optimal resection volume, a calculated resection ratio (CRR) was determined to indicate the excess tissue resection. The mammographic images were used to determine the distances from the centre of the lesion to the border of the specimen, which is an indication of the amount of tissue excised, and the difference between the maximum and minimum distances, which indicates concentricity.28 The post-operative histopathological findings (tumour type, presence of DCIS, multifocality, grade, size and radial margin) and whether extra tissue was submitted at the time of original surgery was also evaluated. Satellite lesions were defined as an area of malignancy separate to the main tumour but within 10 mm and were classified as multifocal for the purpose of analysis. Where final pathological radial margins were outside of the units’ acceptance of clearance but no re-excision was performed, the case notes were reviewed. Data were collected in an Access 2007 database and statistical analysis was conducted using NCSS (2007, NCSS, LLC, Kaysville, UT, USA) software. Proportions were compared using chi-square test and medians using Mann–Whitney U-test. A P-value of 20.1 0–5 5.1–10 10.1–20 >20.1 Unassessable No Yes 0–5 5.1–10 10.1–20 >20.1 Unassessable DCIS Invasive Both Unassessable
4 32 65 14 12 18 22 29 24 98 50 69 32 29 16 2 51 51 24 22
4 (100) 6 (19) 15 (23) 8 (57) 4 (33) 4 (22) 5 (23) 17 (59) 5 (21) 23 (23) 21 (42) 10 (14) 11 (34) 10 (34) 12 (75) 1 (50) 24 (47) 15 (29) 3 (13) 2 (9)
0.00 — — — 0.02 — — — — 0.02 — 0.00 — — — — 0.01 — — —
DCIS, ductal carcinoma in situ.
The strengths of our study are that we are one of only a few groups who have examined an entirely wire-localized cohort and included only those with a definitive malignant preoperative diagnosis. Both the study sites are tertiary referral centres and manage the majority of publicly treated breast cancers in Western Australia. Our median CRR for HWL of 1.98 is in keeping with other published data.27 The median concentricity score of 27 in combination with the low CRR indicates that unnecessary tissue excision was kept to a minimum. Although separate MDMs are held at each site, there is a uniform definition for acceptable margins and an agreed re-excision policy. Both the size of histological margins and the reasons why cases that did not meet our acceptable margin criteria did not undergo re-excision have been evaluated. The specimen radiography data suggest that a larger final histopathological margin is associated with a higher incidence of re-excision. However, those with close margins are more likely to have had extra tissue taken at the time of surgery. This may have been due to identification of a close margin on specimen imaging; however, this could not be reliably assessed in this retrospective audit as it is not always clear from the operation notes whether the re-excision was influenced by the specimen imaging findings. Although there is a general lack of consensus regarding ‘adequate’ margins there have been recent attempts to quantify this. It is important to note that while a margin of 2 mm improves this if the patient is given whole breast radiotherapy.9 The minimum acceptable radial margin for invasive and in situ malignancy remains controversial in Australia and New Zealand. The Association of Breast Surgeons in the UK recommends that breast centres develop their own local protocols for re-operation.32 There are no current Australian guidelines. Further research is needed into developing tools that can help reduce unnecessary re-operations. Removal of larger volumes of tissue to try and reduce the chance of inadequate margins may © 2015 Royal Australasian College of Surgeons
compromise cosmetic results, although the use of level 1 and 2 oncoplastic techniques allows increased volumes of tissue to be removed with proven low recurrence rates.33 Notably, the literature suggests there is no association between volume taken and re-operation rates or larger margins and decreased local recurrence.9 In our audit, 16 patients (11%) had over 10 mm more disease on final pathology than expected and this was a significant predictor for re-excision. Conventional preoperative imaging techniques (mammography and ultrasound) are unable to identify the full extent of all types of malignancy, particularly non-calcified DCIS.34 This limitation makes it difficult to circumvent the need for re-excision in all cases, leading us to suggest that a re-excision rate of 11% could be justified as a current benchmark for standards in breast-conserving surgery.35 The role of preoperative magnetic resonance imaging (MRI) in guiding breast surgery remains controversial,36 although a recently published randomized multicentre study has shown that in young women, preoperative MRI significantly reduced the re-operation rate without increasing the number of overall mastectomies.37 MRI findings that could alter surgical management should be further evaluated with percutaneous biopsy to avoid the risk of over-treatment.38 Where there is MRI biopsy-proven malignant disease that is occult on conventional imaging, biopsy markers inserted at the time of the MRI-guided biopsy can be subsequently targeted for insertion of bracketing hook-wires using ultrasound or mammography. Although there is no published trial evaluating the efficacy of preoperative bracketing of malignant lesions confirmed only on MRI guided biopsy, in improving margin clearance, this approach could potentially reduce re-excision rates. Translation of preoperative MRI findings (where the patient’s breast is in the prone position) to their corresponding location in the supine patient position during surgery is challenging, and this may help explain why it has been difficult to show preoperative MRI can reduce re-excision rates.39 Recent studies using co-registration and
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projection techniques to help address this issue have shown promising results.40,41 Localization methods that give three-dimensional real-time feedback during surgery such as intra-operative ultrasound (IOUS) and radio-guided techniques (injection of radioisotope (ROLL) and radio-guided occult lesion localisation using iodine-125 seed(s) (ROLLIS)) have been shown to reduce re-excision rates.42,43 Unlike ROLLIS (which can be used for almost all lesions), the use of IOUS is restricted to lesions that are sonographically visible. This is an important limitation, given that DCIS lesions are often occult on ultrasound. Specimen imaging techniques that improve identification of involved or close tumour margins at the time of initial surgery can help direct immediate intra-operative re-excision, potentially reducing the need for second surgery. Ultra-sound and tomosynthesis enable assessment of macroscopic margins in three dimensions44,45 and rapidly developing techniques such as near infrared fluorescence optical imaging and optical coherence tomography may allow microscopic identification of involved or close tumour margins.46
Conclusion Preoperative factors such as centrally located tumours and suspicion of DCIS, particularly at the lesion periphery, increase the risk of positive margins and should make the surgeon more cautious when performing surgery. Lesion localization techniques (such as ROLLIS and IOUS) that give the surgeon real-time three-dimensional feedback have the potential to reduce re-excision rates and optimize cosmetic outcome. This audit forms the baseline for a large Australasian randomized controlled trial to evaluate whether the use of ROLLIS for preoperative localization of impalpable breast cancers can reduce re-excision rates compared with conventional HWL (ACTRN12613000655741).
Acknowledgements The authors would like to thank Ms Jill Tinning, Royal Perth Hospital Breast Centre; Dr Paul Riley, Department of Radiology, Sir Charles Gairdner Hospital; Dr John Bourke, Department of Medicine, Sir Charles Gairdner Hospital; Dr Deepthi Dissanayake, Department of Radiology, Royal Perth Hospital; and Ms Jan Tresham, BSWA.
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