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Standardized and reproducible methodology for the comprehensive and systematic assessment of surgical resection margins during breast-conserving surgery for invasive breast cancer.

Povoski SP, Jimenez RE, Wang WP, Xu RX - BMC Cancer (2009)

Bottom Line: Nevertheless, precise determination of the adequacy of BCS has long been debated.Thus, 54.2% (13/24) of patients with additional disease in a re-resection margin would not have been recognized by a standard BCS procedure alone (P < 0.001).Our methodology accurately assesses the adequacy of surgical resection margins for determination of which individuals may need further resection to the affected breast in order to minimize the potential risk of local recurrence while attempting to limit the volume of additional breast tissue excised, as well as to determine which individuals are not realistically amendable to BCS and instead need a completion mastectomy to successfully remove multifocal disease.

View Article: PubMed Central - HTML - PubMed

Affiliation: Division of Surgical Oncology, Department of Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, 43210, USA. stephen.povoski@osumc.edu

ABSTRACT

Background: The primary goal of breast-conserving surgery (BCS) is to completely excise the tumor and achieve "adequate" or "negative" surgical resection margins while maintaining an acceptable level of postoperative cosmetic outcome. Nevertheless, precise determination of the adequacy of BCS has long been debated. In this regard, the aim of the current paper was to describe a standardized and reproducible methodology for comprehensive and systematic assessment of surgical resection margins during BCS.

Methods: Retrospective analysis of 204 BCS procedures performed for invasive breast cancer from August 2003 to June 2007, in which patients underwent a standard BCS resection and systematic sampling of nine standardized re-resection margins (superior, superior-medial, superior-lateral, medial, lateral, inferior, inferior-medial, inferior-lateral, and deep-posterior). Multiple variables (including patient, tumor, specimen, and follow-up variables) were evaluated.

Results: 6.4% (13/204) of patients had positive BCS specimen margins (defined as tumor at inked edge of BCS specimen) and 4.4% (9/204) of patients had close margins (defined as tumor within 1 mm or less of inked edge but not at inked edge of BCS specimen). 11.8% (24/204) of patients had at least one re-resection margin containing additional disease, independent of the status of the BCS specimen margins. 7.1% (13/182) of patients with negative BCS specimen margins (defined as no tumor cells seen within 1 mm or less of inked edge of BCS specimen) had at least one re-resection margin containing additional disease. Thus, 54.2% (13/24) of patients with additional disease in a re-resection margin would not have been recognized by a standard BCS procedure alone (P < 0.001). The nine standardized resection margins represented only 26.8% of the volume of the BCS specimen and 32.6% of the surface area of the BCS specimen.

Conclusion: Our methodology accurately assesses the adequacy of surgical resection margins for determination of which individuals may need further resection to the affected breast in order to minimize the potential risk of local recurrence while attempting to limit the volume of additional breast tissue excised, as well as to determine which individuals are not realistically amendable to BCS and instead need a completion mastectomy to successfully remove multifocal disease.

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Photograph of a typical example of the nine standardized re-resection margins sampled from the superior (S), superior-medial (SM), superior-lateral (SL), medial (M), lateral (L), inferior (I), inferior-medial (IM), inferior-lateral (IL), and deep-posterior (DP) aspects of a left-sided breast-conserving surgery (BCS) resection bed cavity.
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Figure 3: Photograph of a typical example of the nine standardized re-resection margins sampled from the superior (S), superior-medial (SM), superior-lateral (SL), medial (M), lateral (L), inferior (I), inferior-medial (IM), inferior-lateral (IL), and deep-posterior (DP) aspects of a left-sided breast-conserving surgery (BCS) resection bed cavity.

Mentions: Once the BCS specimen was removed, rectangular-shaped pieces of breast tissue were then systematically sampled from nine standardized locations within the perimeter of the resultant BCS resection bed cavity using curved Mayo scissors and/or a #24 surgical blade (Figure 2). These rectangular-shaped pieces of breast tissue were excised with the curved Mayo scissors and/or a #24 surgical blade, instead of with the coagulation mode of the electrocautery, in order to generate no evidence of cautery artifact on that particular surface of each sampled piece of breast tissue. Therefore, in the end, the non-cauterized aspect of each rectangular-shaped piece of breast tissue sampled would represent the surface of the rectangular-shaped piece of breast tissue that was furthest from the corresponding resection margin of the originally submitted BCS specimen that was removed from the affected breast with the coagulation mode of the electrocautery and the cauterized aspect of each rectangular-shaped piece of breast tissue sampled would represent the surface of the rectangular-shaped piece of breast tissue that was abutting the corresponding resection margin of the originally submitted BCS specimen that was removed from the affected breast with the coagulation mode of the electrocautery. In this fashion, the distribution of electrocautery artifact on each rectangular-shaped piece of breast tissue sampled was used by the pathologist to help distinguish the actual true margin surface (non-cauterized surface) from that of the non-margin surface (cauterized surface) of each rectangular-shaped piece of breast tissue sampled. These rectangular-shaped pieces of breast tissue that where systematically sampled from nine standardized locations within the perimeter of the resultant BCS resection bed cavity were designated as originating from the superior, superior-medial, superior-lateral, medial, lateral, inferior, inferior-medial, inferior-lateral, and deep-posterior aspects of the resultant BCS resection bed cavity (Figures 2 and 3). These rectangular-shaped pieces of breast tissue that were systematically sampled from nine standardized locations within the perimeter of the resultant BCS resection bed cavity were designated as the nine standardized re-resection margin specimens, as they are referred to throughout the remainder of the current paper. Since the anterior aspect of the BCS specimen was covered by an overlying skin ellipse (in all but two cases), there was no anterior re-resection margin designation for the resultant BCS resection bed cavity.


Standardized and reproducible methodology for the comprehensive and systematic assessment of surgical resection margins during breast-conserving surgery for invasive breast cancer.

Povoski SP, Jimenez RE, Wang WP, Xu RX - BMC Cancer (2009)

Photograph of a typical example of the nine standardized re-resection margins sampled from the superior (S), superior-medial (SM), superior-lateral (SL), medial (M), lateral (L), inferior (I), inferior-medial (IM), inferior-lateral (IL), and deep-posterior (DP) aspects of a left-sided breast-conserving surgery (BCS) resection bed cavity.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2724549&req=5

Figure 3: Photograph of a typical example of the nine standardized re-resection margins sampled from the superior (S), superior-medial (SM), superior-lateral (SL), medial (M), lateral (L), inferior (I), inferior-medial (IM), inferior-lateral (IL), and deep-posterior (DP) aspects of a left-sided breast-conserving surgery (BCS) resection bed cavity.
Mentions: Once the BCS specimen was removed, rectangular-shaped pieces of breast tissue were then systematically sampled from nine standardized locations within the perimeter of the resultant BCS resection bed cavity using curved Mayo scissors and/or a #24 surgical blade (Figure 2). These rectangular-shaped pieces of breast tissue were excised with the curved Mayo scissors and/or a #24 surgical blade, instead of with the coagulation mode of the electrocautery, in order to generate no evidence of cautery artifact on that particular surface of each sampled piece of breast tissue. Therefore, in the end, the non-cauterized aspect of each rectangular-shaped piece of breast tissue sampled would represent the surface of the rectangular-shaped piece of breast tissue that was furthest from the corresponding resection margin of the originally submitted BCS specimen that was removed from the affected breast with the coagulation mode of the electrocautery and the cauterized aspect of each rectangular-shaped piece of breast tissue sampled would represent the surface of the rectangular-shaped piece of breast tissue that was abutting the corresponding resection margin of the originally submitted BCS specimen that was removed from the affected breast with the coagulation mode of the electrocautery. In this fashion, the distribution of electrocautery artifact on each rectangular-shaped piece of breast tissue sampled was used by the pathologist to help distinguish the actual true margin surface (non-cauterized surface) from that of the non-margin surface (cauterized surface) of each rectangular-shaped piece of breast tissue sampled. These rectangular-shaped pieces of breast tissue that where systematically sampled from nine standardized locations within the perimeter of the resultant BCS resection bed cavity were designated as originating from the superior, superior-medial, superior-lateral, medial, lateral, inferior, inferior-medial, inferior-lateral, and deep-posterior aspects of the resultant BCS resection bed cavity (Figures 2 and 3). These rectangular-shaped pieces of breast tissue that were systematically sampled from nine standardized locations within the perimeter of the resultant BCS resection bed cavity were designated as the nine standardized re-resection margin specimens, as they are referred to throughout the remainder of the current paper. Since the anterior aspect of the BCS specimen was covered by an overlying skin ellipse (in all but two cases), there was no anterior re-resection margin designation for the resultant BCS resection bed cavity.

Bottom Line: Nevertheless, precise determination of the adequacy of BCS has long been debated.Thus, 54.2% (13/24) of patients with additional disease in a re-resection margin would not have been recognized by a standard BCS procedure alone (P < 0.001).Our methodology accurately assesses the adequacy of surgical resection margins for determination of which individuals may need further resection to the affected breast in order to minimize the potential risk of local recurrence while attempting to limit the volume of additional breast tissue excised, as well as to determine which individuals are not realistically amendable to BCS and instead need a completion mastectomy to successfully remove multifocal disease.

View Article: PubMed Central - HTML - PubMed

Affiliation: Division of Surgical Oncology, Department of Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, 43210, USA. stephen.povoski@osumc.edu

ABSTRACT

Background: The primary goal of breast-conserving surgery (BCS) is to completely excise the tumor and achieve "adequate" or "negative" surgical resection margins while maintaining an acceptable level of postoperative cosmetic outcome. Nevertheless, precise determination of the adequacy of BCS has long been debated. In this regard, the aim of the current paper was to describe a standardized and reproducible methodology for comprehensive and systematic assessment of surgical resection margins during BCS.

Methods: Retrospective analysis of 204 BCS procedures performed for invasive breast cancer from August 2003 to June 2007, in which patients underwent a standard BCS resection and systematic sampling of nine standardized re-resection margins (superior, superior-medial, superior-lateral, medial, lateral, inferior, inferior-medial, inferior-lateral, and deep-posterior). Multiple variables (including patient, tumor, specimen, and follow-up variables) were evaluated.

Results: 6.4% (13/204) of patients had positive BCS specimen margins (defined as tumor at inked edge of BCS specimen) and 4.4% (9/204) of patients had close margins (defined as tumor within 1 mm or less of inked edge but not at inked edge of BCS specimen). 11.8% (24/204) of patients had at least one re-resection margin containing additional disease, independent of the status of the BCS specimen margins. 7.1% (13/182) of patients with negative BCS specimen margins (defined as no tumor cells seen within 1 mm or less of inked edge of BCS specimen) had at least one re-resection margin containing additional disease. Thus, 54.2% (13/24) of patients with additional disease in a re-resection margin would not have been recognized by a standard BCS procedure alone (P < 0.001). The nine standardized resection margins represented only 26.8% of the volume of the BCS specimen and 32.6% of the surface area of the BCS specimen.

Conclusion: Our methodology accurately assesses the adequacy of surgical resection margins for determination of which individuals may need further resection to the affected breast in order to minimize the potential risk of local recurrence while attempting to limit the volume of additional breast tissue excised, as well as to determine which individuals are not realistically amendable to BCS and instead need a completion mastectomy to successfully remove multifocal disease.

Show MeSH
Related in: MedlinePlus