A comparative study of perioperative techniques to attain negative margins and spare healthy breast tissue in breast conserving surgery

Abstract

BACKGROUND AND AIM: Traditionally lumpectomy as a part of breast-conserving surgery (BCS) is performed by palpation-guided method leading to positive margins and large excision volumes. There is no evidence suggesting that wide margin excisions decrease intra-breast tumour recurrence. Various perioperative techniques are used for margin assessment. We aimed to compare three commonly used techniques, i.e., ultrasound-guided surgery, palpation-guided surgery and cavity shaving for attaining negative margins and estimating the extent of healthy breast tissue resection. METHOD: A prospective comparative study was performed on 90 patients who underwent breast conservation surgery for early breast cancer between August 2018 and June 2019. Tumour excision with a minimum of 1 cm margin was done either using ultrasound, palpation or cavity shaving. Histopathological evaluation was done to assess the margin status and excess amount of resected normal breast tissue. Calculated resection ratio (CRR) defining the excess amount of the resected breast tissue was achieved by dividing the total resection volume (TRV) by optimal resection volume (ORV). The time taken for excision was also recorded. RESULTS: Histopathology of all 90 patients (30 in each group) revealed a negative resection margin in 93.3% of 30 patients in palpation-guided surgery group and 100% in both ultrasound-guided surgery and cavity shaving groups. Two patients (6.7%) from the cavity shaving group had positive margins on initial lumpectomy but shave margins were negative. TRV was significantly less in the ultrasound-guided surgery group compared to the palpation-guided surgery group and cavity shaving group (76.9 cm3, 94.7 cm3 and 126.3 cm3 respectively; p < 0.0051). CRR was 1.2 in ultrasound group compared to 1.9 in palpation group and 2.1 in cavity shave group which was also statistically significant (p < 0.0001). Excision time was significantly less (p < 0.001) in palpation-guided surgery group (13.8 min) compared to cavity shaving group (15.1 min) and ultrasound-guided group (19.4 min). CONCLUSION: Ultrasound-guided surgery is more accurate in attaining negative margins with the removal of least amount of healthy breast tissue compared to palpation-guided surgery and cavity shaving.

Intraoperative Frozen Section Margin Positive in Breast-Conserving Surgery; Current Status and Ways to Reduce It.

“…Also, preoperative microwave ablation is reported to be another technique which could guide BCS with better result of resection margin and without impairing sentinel lymph node biopsy [10]. In the operation, tumor localization using intraoperative ultrasound can help attaining negative margins without removal of much healthy breast tissue [11][12][13]. Multiple radioactive seed is another means for tumor localization with good result of negative resection margin [14].…”

AGO-Empfehlungen zur operativen Therapie des Mammakarzinoms: Update 2022

“…Auch beim palpablen Mammakarzinom sind die Vorteile der intraoperativen Sonografie im Vergleich zur palpationsgeführten Operation eindeutig: So kann die R0-Resektionsrate erhöht und die Nachresektionsrate gesenkt werden 11 12 . Interessanterweise konnten Resektionsvolumina durch den Einsatz der intraoperativen Sonografie in einigen Studien reduziert werden 12 13 14 . So erlaubt die Technik, gezielt den Tumor zu entfernen und gleichzeitig das gesunde Gewebe zu schonen.…”

Intraoperative Ultrasound-Guided Excision of Non-Palpable and Palpable Breast Cancer: Systematic Review and Meta-Analysis

“…Randomized controlled trials 3 RCTs have compared IOUS with palpation-guided excision in palpable breast cancer (▶ Table 2). In 2 trials [21,22], patients receiving neoadjuvant therapy were excluded. In the third trial, 12 % of enrolled patients underwent breast-conserving surgery after neoadjuvant treatment [23].…”

“…In the third RCT on IOUS in palpable BC, 90 patients were randomized to one of 3 arms: IOUS-guided excision, palpationguided excision, or palpation-guided excision with cavity shaving [22]. The participating breast surgeons had a minimum of 5 years of experience in the field.…”