Get 20M+ Full-Text Papers For Less Than $1.50/day. Subscribe now for You or Your Team.

Learn More →

The Beneficial Impact of Intraoperative Ultrasound on Resection Margin Status during Breast Conserving Surgery

The Beneficial Impact of Intraoperative Ultrasound on Resection Margin Status during Breast... Hindawi International Journal of Surgical Oncology Volume 2022, Article ID 2268821, 5 pages https://doi.org/10.1155/2022/2268821 Research Article The Beneficial Impact of Intraoperative Ultrasound on Resection Margin Status during Breast Conserving Surgery 1 2 1 Osama Almezaien , Ahmed Mohamed Eldeeb , Abdelfattah Kalmoush , 1 1 1 Mohamed Shaaban Nassar , Tarek Zaghlol Mohamed , Mohamed Sobhy Shaaban , 1 1 Mohamed Ibrahim Henish , Sobhy Teama , 1 1 Saed Abdolmonem Elgohary Khalafallah , and Lofty A. Ibrahim Department of General Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt Department of Radiology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt Correspondence should be addressed to Osama Almezaien; osamafathy.216@azhar.edu.eg and Abdelfattah Kalmoush; abd-elfattahmorsi.216@azhar.edu.eg Received 4 July 2022; Revised 5 November 2022; Accepted 23 November 2022; Published 7 December 2022 Academic Editor: Gaetano Gallo Copyright © 2022 Osama Almezaien et al. Tis is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. Surgical resection with clear surgical cut margins is the mainstay of managing malignant breast neoplasms. Multiple techniques have been suggested to enhance resection status during breast-conserving surgery (BCS), including intraoperative ultrasonography (IOUS). Herein, we conducted the current investigation to reveal the beneft of IOUS on the achievement of R0 resection. Patients and Methods. Tis retrospective investigation included 140 patients who underwent BCS. Tey were divided into two groups: the IOUS group (40 cases) and the control group (100 cases). Our primary objective was to determine the free resection margin status (R0). Results. Both study groups expressed statistically comparable demographic and clinical data. Additionally, histopathological examination revealed no signifcant diference between the two groups regarding the tumor type, stage, or grade. Nonetheless, the R0 resection margin was more frequently encountered in association with IOUS application (97.5% compared to 79% in the control group), and that diference was statistically signifcant (p � 0.007). Conclusion. Te application of IOUS has a signifcant benefcial impact on the outcomes of BCS. It is associated with a marked decline in positive resection margins, and its application should be encouraged in the breast oncological practice. mastectomy, or even adjuvant radiotherapy [5–7]. Tere- 1. Introduction fore, it is crucial to achieve clear surgical cut margins during In Egypt, breast cancer is the most common malignant BCS to enhance patients’ oncological outcomes [8]. neoplasm detected in the female population, accounting for Multiple methods have been applied for better tumor about 30% of malignant neoplasms in this population [1]. localization during BCS, like radioactive seeds, wire place- Tanks to efective screening programs and increased public ment, and intraoperative ultrasonography (IOUS). Te awareness, breast cancer patients are often detected at early former two methods have their own drawbacks. Te stages [2, 3]. implementation of radioactive seeds needs to be one day Surgical resection is still the main management method before surgery. It is also an invasive procedure that has a for breast cancer, and breast-conserving surgery (BCS) is high fnancial cost [9]. Likewise, wire localization needs to be preferable for patients who have earlier stages [4]. Te done in a separate setting before surgery, and it is associated primary goal of surgery is to obtain cut margins free of with increased patient anxiety [10]. tumor tissue. Infltrated margins are associated with high Contrarily, IOUS is widely available in most surgical postoperative recurrence rates, which will need re-excision, theatres nowadays. It could be done in the same operative 2 International Journal of Surgical Oncology 1.2. Statistical Analysis. Te Statistical Package for Social setting without scheduling problems or increased exposure to radiation [11–13]. IOUS of the excised surgical specimen Science (version 27 for Windows (IBM SPSS Inc., Chicago, could be used to ensure appropriate margins surrounding IL, USA) was utilized for data tabulation and analysis. the whole specimen. If a defcient margin is detected the Quantitative data were tested for normality using the Sha- surgeon is informed and a re-excision of the infltrated piro–Walk test and then expressed as the mean± SD or region is performed within the same primary setting [9, 14]. median (min-max). To compare two independent groups of Te previous technique has recently been adopted in our parametric quantitative data, independent samples t-test was center, especially with the lack of other expensive locali- used, and compares two independent groups of nonpara- zation techniques in a resource-limited country like Egypt. metric quantitative data, independent samples t-test Qual- Tus, the current investigation was conducted to reveal the itative data were expressed as numbers and relative beneft of IOUS on the achievement of R0 resection. percentages. To compare two independent groups of qual- itative data, the chi-square (Fischer’s exact test or Monte- Carlo test) were used as appropriate. A p value of 0.05 or less 1.1. Patients and Methods. Tis retrospective investigation was considered to be signifcant. was carried out at the Al-Azhar University General Surgery Department following approval from the local scientifc 2. Results committee of the same university. We collected the data of all female patients who underwent BCS for breast cancer at our Te included women had mean ages of 46.5 and 45.26 years institute during the period between January 2019 and De- in the IOUS and control groups, respectively. Diabetes cember 2021. Women who had bilateral lesions or who mellitus was present in 7.5% and 6% of patients, while underwent wire-guided surgery or mastectomy were hypertension was reported by 7.5% and 5% of patients in the excluded. same two groups, respectively. Only one patient (1%) had All patients were subjected to history taking (including chronic kidney disease in the control group. Previous risk factors for cancer, family history, and previous neo- chemotherapy was received in 22.5% and 26% of cases, adjuvant therapy), a local breast examination, and a routine whereas hormonal therapy was commenced for 5% and 8% preoperative laboratory workup. Other investigations in- of patients in the same two study groups, respectively. All of cluded breast mammography, US, and US-guided core the previous variables were statistically comparable between biopsy. the two study groups (p> 0.05) Table 1. Te allocated 140 patients were divided into two groups Histopathological analysis of the excised specimen according to the use of IOUS: the IOUS group included 40 revealed invasive ductal adenocarcinoma in most of the study patients, and the control group included the remaining 100 cases (87.5% and 81% of patients in the two study groups, cases. Te BCS was performed by an experienced surgeon respectively), followed by invasive lobular carcinoma (10% under general anesthesia, and these procedures included and 12% of patients in the same two groups, respectively). quadrantectomy, segmental resection, or lumpectomy. Te Other fndings included tubular and medullary carcinomas. choice of the operation was mainly dependent on the op- Table 2 shows the absence of any signifcant diferences be- erator’s choice. Te excised specimen was marked by silk tween the two groups regarding the previous parameter. sutures to be correctly oriented for the subsequent radio- According to the pathological TNM classifcation logical or histopathological examinations. (pTNM), most patients had the T1 stage (87.5% and 81% in In the IOUS group, the specimen was immersed in a the two groups, respectively), while the T2 stage was present water bath and then scanned by the US probe of the Toshiba in 10% and 16% of patients in the same two groups, re- Aplio 500 device using the linear probe (10 MHz) by a ra- spectively. Te remaining cases had the T3 stage (Table 3). diologist experienced in breast ultrasonography. Images Tumor grade was also comparable between the two study were obtained for the six surfaces of the surgical specimen, groups (Table 4). Grade 2 was the most common one (70% and the surgeon was informed if the tumor tissue infltrated and 76% of patients in the two groups, respectively), fol- the cut margin or if the resected margin was too small or lowed by grade 1 (22.5% and 14% in the same groups, re- unclear. Tese cases were managed by re-excision in the spectively). Te remaining cases had grade 3 lesions. same setting in the same direction of the infltrated or When it comes to our primary outcome, the application suspected surface. of IOUS was associated with higher R0 resection rates After surgery, the specimen was sent for histopatho- (97.5% versus 79% in controls—p � 0.007) (Table 5). IOUS logical analysis. Tumor type, grade, and stage were assessed. application led to a change in the resection limits in four In addition, the surgical cut margin was classifed as negative patients (10%), as US assessment revealed infltrated margin when the distance between the tumor and the margin was in these patients, and they were managed by re-excision in ≥1 mm (R0) or positive when it was infltrated by tumor the same primary setting. tissue (R1) [15]. Te histopathological fndings were con- sidered the standard gold measurement of cut margin in- 3. Discussion fltration in the current study. Te primary outcome of our investigation was to elu- Complete excision of breast cancer is still the main step in cidate if the application of IOUS helped in the increase in R0 the management of such pathology, in spite of great ad- detection rates or not. vances in the methods of diagnosis and treatment. BCS is International Journal of Surgical Oncology 3 Table 1: Patient demographic and clinical criteria in the two study groups. Variables IOUS groups (n � 40) Control groups (n � 100) p values Age (years) 46.50± 7.73 45.26± 8.46 0.424 Comorbidities (i) Diabetes 3 (7.5%) 6 (6%) 0.744 (ii) Hypertension 3 (7.5%) 5 (5%) 0.565 (iii) Chronic kidney disease 0 (0%) 1 (1%) 0.526 Previous treatment (i) Chemotherapy 9 (22.5%) 26 (26%) 0.666 (ii) Hormonal therapy 2 (5%) 8 (8%) 0.534 Table 2: Tumor histopathology in the two study groups. Histopathology IOUS groups (n � 40) Control groups (n � 100) p values (i) Invasive ductal carcinoma 33 (82.5%) 86 (86%) (ii) Invasive lobular carcinoma 4 (10%) 12 (12%) (iii) Tubular carcinoma 2 (5%) 2 (2%) 0.315 (iv) Medullary carcinoma 1 (2.5%) 0 (0%) Table 3: Tumor pathological stage in the two study groups. pTNM stages IOUS groups (n � 40) Control groups (n � 100) p values (i) T1 35 (87.5%) 81 (81%) (ii) T2 4 (10%) 16 (16%) 0.641 (iii) T3 1 (2.5%) 3 (3%) Table 4: Tumor grade in the two study groups. pTNM grades IOUS groups (n � 40) Control groups (n � 100) p values (i) Grade 1 9 (22.5%) 14 (14%) (ii) Grade 2 28 (70%) 76 (76%) 0.452 (iii) Grade 3 3 (7.5%) 10 (10%) Table 5: Resection margin according to the fnal histopathological examination. Resection status IOUS groups (n � 40) Control groups (n � 100) p values (i) R0 39 (97.5%) 79 (79%) 0.007 (ii) R1 1 (2.5%) 11 (11%) preferred by surgeons for localized lesions as it is associated favor of the IOUS group rather than the controls. Our with better cosmetic outcomes and patient satisfaction. Also, fndings revealed a signifcant increase in R0 resection it has a comparable oncological outcome to the radical margins in association with IOUS application (97.5% vs. mastectomy operation when performed in selected patients. 79% in controls—p< 0.05). Tese fndings should have a However, some malignant breast neoplasms have micro- positive impact on postoperative oncological outcomes and scopic spread that may not be noticed by the surgeon the need for reoperation, although not being studied in our intraoperatively and detected on the subsequent patholog- investigation. ical analysis of the specimen [14, 16]. Eichler and his associates agreed with our fndings, as R0 Tese patients require additional interventions for the resection was obtained in 96.4% of IOUS patients, compared to 82.5% of controls, with a signifcant diference between residual tumor tissue, including re-excision. Terefore, it is crucial to minimize this scenario to improve oncological them (p< 0.05) [14]. Moore et al. also reported that only one outcomes, decrease the need for reoperation, and decrease patient (3.5%) in the IOUS group had infltrated margins, fnancial healthcare costs [17, 18]. compared to seven patients (29%) in the control group, with Te application of IOUS was greatly benefcial for this a signifcant diference in statistical analysis (p < 0.05) [19]. dilemma, and that was proved in the current investigation. Krekel et al. also noticed a signifcant decline in re- First of all, one could notice the absence of any signifcant section margin involvement with IOUS application (p diferences between the IOUS and control groups regarding � 0.009). Infltrated margins were encountered in 3% and most of the tumor criteria, despite the retrospective nature of 17% of patients in the IOUS and control groups, respec- our study. Tat should reduce any bias skewing our results in tively [20]. 4 International Journal of Surgical Oncology [6] C. Cellini, T. L. Huston, D. Martins et al., “Multiple re-ex- Vispute et al. reported that positive surgical cut margins cisions versus mastectomy in patients with persistent residual were more encountered in the control group (14.28%) disease following breast conservation surgery,” Te American compared to only 3.22% when the IOUS was used. Despite Journal of Surgery, vol. 189, no. 6, pp. 662–666, 2005. that diference, the statistical analysis revealed its non- [7] A. Luini, J. Rososchansky, G. Gatti et al., “Te surgical margin signifcance [16]. Moreover, Oshla and his colleagues re- status after breast-conserving surgery: discussion of an open ported that IOUS was helpful in decreasing reoperation rates issue,” Breast Cancer Research and Treatment, vol. 113, no. 2, by localization of neoplastic tissue in the resected area and pp. 397–402, 2009. thus, achieving R0 margins [21]. [8] J. Lee, H. Y. Park, W. W. Kim et al., “Clinical efcacy of In our study, although one patient (2.5%) was missed by intraoperative ultrasound for margin assessment in breast- IOUS and proved to have infltrated margins on the path- conserving surgery,” Breast Journal, vol. 26, no. 11, ological examination, another four patients (10%) were pp. 2308–2311, 2020. discovered by the same modality to have infltrated margins, [9] J. M. Chakedis, A. Tang, G. E. Kuehner et al., “Implementation and they were managed by re-excision in the same operative of intraoperative ultrasound localization for breast-conserv- setting. Although the failure rate was too low (2.5%), it is ing surgery in a large, integrated health care system is feasible expected to improve with the increased learning curve with and efective,” Annals of Surgical Oncology, vol. 28, no. 10, more US specimen examinations. pp. 5648–5656, 2021. [10] M. K. Hayes, “Update on preoperative breast localization,” Te current study has some limitations; being retro- Radiologic Clinics of North America, vol. 55, no. 3, pp. 591– spective in nature, along with its application in a single 603, 2017. medical center, are the main drawbacks. Tis should en- [11] J. H. Volders, M. H. Haloua, N. M. Krekel et al., “Intra- courage researchers to conduct more studies, including operative ultrasound guidance in breast-conserving surgery more patients from diferent oncological centers in the near shows superiority in oncological outcome, long-term cos- future. metic and patient-reported outcomes: fnal outcomes of a randomized controlled trial (COBALT),” European Journal of Surgical Oncology, vol. 43, no. 4, pp. 649–657, 2017. 4. Conclusions [12] N. M. Krekel, A. M. Lopes Cardozo, S. Muller, E. Bergers, Te application of IOUS has a signifcant benefcial impact S. Meijer, and M. P. van den Tol, “Optimising surgical ac- on the outcomes of BCS. It is associated with a marked curacy in palpable breast cancer with intra-operative breast ultrasound--feasibility and surgeons’ learning curve,” Euro- decline in positive resection margins, and its application pean Journal of Surgical Oncology, vol. 37, no. 12, pp. 1044– should be encouraged in the breast oncological practice. 1050, 2011. [13] H. Pan, N. Wu, H. Ding et al., “Intraoperative ultrasound Data Availability guidance is associated with clear lumpectomy margins for breast cancer: a systematic review and meta-analysis,” PLoS Te data used to support the fndings of this study are One, vol. 8, no. 9, Article ID e74028, 2013. available from corresponding authors upon request. [14] C. Eichler, A. Hubbel, ¨ V. Zarghooni et al., “Intraoperative ultrasound: improved resection rates in breast-conserving surgery,” Anticancer Research, vol. 32, no. 3, pp. 1051–1056, Conflicts of Interest [15] H. Eggemann, T. Ignatov, S. D. Costa, and A. Ignatov, Te authors declare that they have no conficts of interest. “Accuracy of ultrasound-guided breast-conserving surgery in the determination of adequate surgical margins,” Breast References Cancer Research and Treatment, vol. 145, no. 1, pp. 129–136, [1] A. S. Ibrahim, H. M. Khaled, N. N. Mikhail, H. Baraka, and [16] T. Vispute, V. Seenu, R. Parshad et al., “Comparison of re- H. Kamel, “Cancer incidence in Egypt: results of the national section margins and cosmetic outcome following intra- population-based cancer registry program,” J Cancer Epi- operative ultrasound-guided excision versus conventional demiol, vol. 2014, Article ID 437971, 2014. palpation-guided breast conservation surgery in breast can- [2] C. Coleman, “Early detection and screening for breast can- cer: a randomized controlled trial,” Indian Journal of Cancer, cer,” Seminars in Oncology Nursing, vol. 33, no. 2, pp.141–155, vol. 55, no. 4, pp. 361–365, 2018. [17] L. Barellini, M. Marcasciano, F. Lo Torto, A. Fausto, [3] R. A. da Costa Vieira, G. Biller, G. Uemura, C. A. Ruiz, and D. Ribufo, and D. Casella, “Intraoperative ultrasound and M. P. Curado, “Breast cancer screening in developing oncoplastic combined approach: an additional tool for the countries,” Clinics, vol. 72, no. 4, pp. 244–253, 2017. oncoplastic surgeon to obtain tumor-free margins in breast [4] Z. H. Sun, C. Chen, X. W. Kuang, J. L. Song, S. R. Sun, and conservative surgery-A 2-year single-center prospective W. X. Wang, “Breast surgery for young women with early- study,” Clinical Breast Cancer, vol. 20, no. 3, pp. e290–e294, stage breast cancer: mastectomy or breast-conserving ther- apy?” Medicine (Baltimore), vol.100, no.18, Article ID e25880, [18] M. M. Pop, S. Cristian, O. Hanko-Bauer, D. V. Ghiga, and R. Georgescu, “Obtaining adequate surgical margin status in [5] D. Aziz, E. Rawlinson, S. A. Narod et al., “Te role of reex- cision for positive margins in optimizing local disease control breast-conservation therapy: intraoperative ultrasound- guided resection versus specimen mammography,” Medicine after breast-conserving surgery for cancer,” Breast Journal, vol. 12, no. 4, pp. 331–337, 2006. and Pharmacy Reports, vol. 91, no. 2, pp. 197–202, 2018. International Journal of Surgical Oncology 5 [19] M. M. Moore, L. A. Whitney, L. Cerilli et al., “Intraoperative ultrasound is associated with clear lumpectomy margins for palpable infltrating ductal breast cancer,” Annals of Surgery, vol. 233, no. 6, pp. 761–768, 2001. [20] N. M. Krekel, M. H. Haloua, A. M. Lopes Cardozo et al., “Intraoperative ultrasound guidance for palpable breast cancer excision (COBALT trial): a multicentre, randomised controlled trial,” Te Lancet Oncology, vol. 14, no. 1, pp. 48–54, 2013. [21] O. Olsha, D. Shemesh, M. Carmon et al., “Resection margins in ultrasound-guided breast-conserving surgery,” Annals of Surgical Oncology, vol. 18, no. 2, pp. 447–452, 2011. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png International Journal of Surgical Oncology Hindawi Publishing Corporation

Loading next page...
 
/lp/hindawi-publishing-corporation/the-beneficial-impact-of-intraoperative-ultrasound-on-resection-margin-eydxUH2GSd

References (21)

Publisher
Hindawi Publishing Corporation
ISSN
2090-1402
eISSN
2090-1410
DOI
10.1155/2022/2268821
Publisher site
See Article on Publisher Site

Abstract

Hindawi International Journal of Surgical Oncology Volume 2022, Article ID 2268821, 5 pages https://doi.org/10.1155/2022/2268821 Research Article The Beneficial Impact of Intraoperative Ultrasound on Resection Margin Status during Breast Conserving Surgery 1 2 1 Osama Almezaien , Ahmed Mohamed Eldeeb , Abdelfattah Kalmoush , 1 1 1 Mohamed Shaaban Nassar , Tarek Zaghlol Mohamed , Mohamed Sobhy Shaaban , 1 1 Mohamed Ibrahim Henish , Sobhy Teama , 1 1 Saed Abdolmonem Elgohary Khalafallah , and Lofty A. Ibrahim Department of General Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt Department of Radiology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt Correspondence should be addressed to Osama Almezaien; osamafathy.216@azhar.edu.eg and Abdelfattah Kalmoush; abd-elfattahmorsi.216@azhar.edu.eg Received 4 July 2022; Revised 5 November 2022; Accepted 23 November 2022; Published 7 December 2022 Academic Editor: Gaetano Gallo Copyright © 2022 Osama Almezaien et al. Tis is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. Surgical resection with clear surgical cut margins is the mainstay of managing malignant breast neoplasms. Multiple techniques have been suggested to enhance resection status during breast-conserving surgery (BCS), including intraoperative ultrasonography (IOUS). Herein, we conducted the current investigation to reveal the beneft of IOUS on the achievement of R0 resection. Patients and Methods. Tis retrospective investigation included 140 patients who underwent BCS. Tey were divided into two groups: the IOUS group (40 cases) and the control group (100 cases). Our primary objective was to determine the free resection margin status (R0). Results. Both study groups expressed statistically comparable demographic and clinical data. Additionally, histopathological examination revealed no signifcant diference between the two groups regarding the tumor type, stage, or grade. Nonetheless, the R0 resection margin was more frequently encountered in association with IOUS application (97.5% compared to 79% in the control group), and that diference was statistically signifcant (p � 0.007). Conclusion. Te application of IOUS has a signifcant benefcial impact on the outcomes of BCS. It is associated with a marked decline in positive resection margins, and its application should be encouraged in the breast oncological practice. mastectomy, or even adjuvant radiotherapy [5–7]. Tere- 1. Introduction fore, it is crucial to achieve clear surgical cut margins during In Egypt, breast cancer is the most common malignant BCS to enhance patients’ oncological outcomes [8]. neoplasm detected in the female population, accounting for Multiple methods have been applied for better tumor about 30% of malignant neoplasms in this population [1]. localization during BCS, like radioactive seeds, wire place- Tanks to efective screening programs and increased public ment, and intraoperative ultrasonography (IOUS). Te awareness, breast cancer patients are often detected at early former two methods have their own drawbacks. Te stages [2, 3]. implementation of radioactive seeds needs to be one day Surgical resection is still the main management method before surgery. It is also an invasive procedure that has a for breast cancer, and breast-conserving surgery (BCS) is high fnancial cost [9]. Likewise, wire localization needs to be preferable for patients who have earlier stages [4]. Te done in a separate setting before surgery, and it is associated primary goal of surgery is to obtain cut margins free of with increased patient anxiety [10]. tumor tissue. Infltrated margins are associated with high Contrarily, IOUS is widely available in most surgical postoperative recurrence rates, which will need re-excision, theatres nowadays. It could be done in the same operative 2 International Journal of Surgical Oncology 1.2. Statistical Analysis. Te Statistical Package for Social setting without scheduling problems or increased exposure to radiation [11–13]. IOUS of the excised surgical specimen Science (version 27 for Windows (IBM SPSS Inc., Chicago, could be used to ensure appropriate margins surrounding IL, USA) was utilized for data tabulation and analysis. the whole specimen. If a defcient margin is detected the Quantitative data were tested for normality using the Sha- surgeon is informed and a re-excision of the infltrated piro–Walk test and then expressed as the mean± SD or region is performed within the same primary setting [9, 14]. median (min-max). To compare two independent groups of Te previous technique has recently been adopted in our parametric quantitative data, independent samples t-test was center, especially with the lack of other expensive locali- used, and compares two independent groups of nonpara- zation techniques in a resource-limited country like Egypt. metric quantitative data, independent samples t-test Qual- Tus, the current investigation was conducted to reveal the itative data were expressed as numbers and relative beneft of IOUS on the achievement of R0 resection. percentages. To compare two independent groups of qual- itative data, the chi-square (Fischer’s exact test or Monte- Carlo test) were used as appropriate. A p value of 0.05 or less 1.1. Patients and Methods. Tis retrospective investigation was considered to be signifcant. was carried out at the Al-Azhar University General Surgery Department following approval from the local scientifc 2. Results committee of the same university. We collected the data of all female patients who underwent BCS for breast cancer at our Te included women had mean ages of 46.5 and 45.26 years institute during the period between January 2019 and De- in the IOUS and control groups, respectively. Diabetes cember 2021. Women who had bilateral lesions or who mellitus was present in 7.5% and 6% of patients, while underwent wire-guided surgery or mastectomy were hypertension was reported by 7.5% and 5% of patients in the excluded. same two groups, respectively. Only one patient (1%) had All patients were subjected to history taking (including chronic kidney disease in the control group. Previous risk factors for cancer, family history, and previous neo- chemotherapy was received in 22.5% and 26% of cases, adjuvant therapy), a local breast examination, and a routine whereas hormonal therapy was commenced for 5% and 8% preoperative laboratory workup. Other investigations in- of patients in the same two study groups, respectively. All of cluded breast mammography, US, and US-guided core the previous variables were statistically comparable between biopsy. the two study groups (p> 0.05) Table 1. Te allocated 140 patients were divided into two groups Histopathological analysis of the excised specimen according to the use of IOUS: the IOUS group included 40 revealed invasive ductal adenocarcinoma in most of the study patients, and the control group included the remaining 100 cases (87.5% and 81% of patients in the two study groups, cases. Te BCS was performed by an experienced surgeon respectively), followed by invasive lobular carcinoma (10% under general anesthesia, and these procedures included and 12% of patients in the same two groups, respectively). quadrantectomy, segmental resection, or lumpectomy. Te Other fndings included tubular and medullary carcinomas. choice of the operation was mainly dependent on the op- Table 2 shows the absence of any signifcant diferences be- erator’s choice. Te excised specimen was marked by silk tween the two groups regarding the previous parameter. sutures to be correctly oriented for the subsequent radio- According to the pathological TNM classifcation logical or histopathological examinations. (pTNM), most patients had the T1 stage (87.5% and 81% in In the IOUS group, the specimen was immersed in a the two groups, respectively), while the T2 stage was present water bath and then scanned by the US probe of the Toshiba in 10% and 16% of patients in the same two groups, re- Aplio 500 device using the linear probe (10 MHz) by a ra- spectively. Te remaining cases had the T3 stage (Table 3). diologist experienced in breast ultrasonography. Images Tumor grade was also comparable between the two study were obtained for the six surfaces of the surgical specimen, groups (Table 4). Grade 2 was the most common one (70% and the surgeon was informed if the tumor tissue infltrated and 76% of patients in the two groups, respectively), fol- the cut margin or if the resected margin was too small or lowed by grade 1 (22.5% and 14% in the same groups, re- unclear. Tese cases were managed by re-excision in the spectively). Te remaining cases had grade 3 lesions. same setting in the same direction of the infltrated or When it comes to our primary outcome, the application suspected surface. of IOUS was associated with higher R0 resection rates After surgery, the specimen was sent for histopatho- (97.5% versus 79% in controls—p � 0.007) (Table 5). IOUS logical analysis. Tumor type, grade, and stage were assessed. application led to a change in the resection limits in four In addition, the surgical cut margin was classifed as negative patients (10%), as US assessment revealed infltrated margin when the distance between the tumor and the margin was in these patients, and they were managed by re-excision in ≥1 mm (R0) or positive when it was infltrated by tumor the same primary setting. tissue (R1) [15]. Te histopathological fndings were con- sidered the standard gold measurement of cut margin in- 3. Discussion fltration in the current study. Te primary outcome of our investigation was to elu- Complete excision of breast cancer is still the main step in cidate if the application of IOUS helped in the increase in R0 the management of such pathology, in spite of great ad- detection rates or not. vances in the methods of diagnosis and treatment. BCS is International Journal of Surgical Oncology 3 Table 1: Patient demographic and clinical criteria in the two study groups. Variables IOUS groups (n � 40) Control groups (n � 100) p values Age (years) 46.50± 7.73 45.26± 8.46 0.424 Comorbidities (i) Diabetes 3 (7.5%) 6 (6%) 0.744 (ii) Hypertension 3 (7.5%) 5 (5%) 0.565 (iii) Chronic kidney disease 0 (0%) 1 (1%) 0.526 Previous treatment (i) Chemotherapy 9 (22.5%) 26 (26%) 0.666 (ii) Hormonal therapy 2 (5%) 8 (8%) 0.534 Table 2: Tumor histopathology in the two study groups. Histopathology IOUS groups (n � 40) Control groups (n � 100) p values (i) Invasive ductal carcinoma 33 (82.5%) 86 (86%) (ii) Invasive lobular carcinoma 4 (10%) 12 (12%) (iii) Tubular carcinoma 2 (5%) 2 (2%) 0.315 (iv) Medullary carcinoma 1 (2.5%) 0 (0%) Table 3: Tumor pathological stage in the two study groups. pTNM stages IOUS groups (n � 40) Control groups (n � 100) p values (i) T1 35 (87.5%) 81 (81%) (ii) T2 4 (10%) 16 (16%) 0.641 (iii) T3 1 (2.5%) 3 (3%) Table 4: Tumor grade in the two study groups. pTNM grades IOUS groups (n � 40) Control groups (n � 100) p values (i) Grade 1 9 (22.5%) 14 (14%) (ii) Grade 2 28 (70%) 76 (76%) 0.452 (iii) Grade 3 3 (7.5%) 10 (10%) Table 5: Resection margin according to the fnal histopathological examination. Resection status IOUS groups (n � 40) Control groups (n � 100) p values (i) R0 39 (97.5%) 79 (79%) 0.007 (ii) R1 1 (2.5%) 11 (11%) preferred by surgeons for localized lesions as it is associated favor of the IOUS group rather than the controls. Our with better cosmetic outcomes and patient satisfaction. Also, fndings revealed a signifcant increase in R0 resection it has a comparable oncological outcome to the radical margins in association with IOUS application (97.5% vs. mastectomy operation when performed in selected patients. 79% in controls—p< 0.05). Tese fndings should have a However, some malignant breast neoplasms have micro- positive impact on postoperative oncological outcomes and scopic spread that may not be noticed by the surgeon the need for reoperation, although not being studied in our intraoperatively and detected on the subsequent patholog- investigation. ical analysis of the specimen [14, 16]. Eichler and his associates agreed with our fndings, as R0 Tese patients require additional interventions for the resection was obtained in 96.4% of IOUS patients, compared to 82.5% of controls, with a signifcant diference between residual tumor tissue, including re-excision. Terefore, it is crucial to minimize this scenario to improve oncological them (p< 0.05) [14]. Moore et al. also reported that only one outcomes, decrease the need for reoperation, and decrease patient (3.5%) in the IOUS group had infltrated margins, fnancial healthcare costs [17, 18]. compared to seven patients (29%) in the control group, with Te application of IOUS was greatly benefcial for this a signifcant diference in statistical analysis (p < 0.05) [19]. dilemma, and that was proved in the current investigation. Krekel et al. also noticed a signifcant decline in re- First of all, one could notice the absence of any signifcant section margin involvement with IOUS application (p diferences between the IOUS and control groups regarding � 0.009). Infltrated margins were encountered in 3% and most of the tumor criteria, despite the retrospective nature of 17% of patients in the IOUS and control groups, respec- our study. Tat should reduce any bias skewing our results in tively [20]. 4 International Journal of Surgical Oncology [6] C. Cellini, T. L. Huston, D. Martins et al., “Multiple re-ex- Vispute et al. reported that positive surgical cut margins cisions versus mastectomy in patients with persistent residual were more encountered in the control group (14.28%) disease following breast conservation surgery,” Te American compared to only 3.22% when the IOUS was used. Despite Journal of Surgery, vol. 189, no. 6, pp. 662–666, 2005. that diference, the statistical analysis revealed its non- [7] A. Luini, J. Rososchansky, G. Gatti et al., “Te surgical margin signifcance [16]. Moreover, Oshla and his colleagues re- status after breast-conserving surgery: discussion of an open ported that IOUS was helpful in decreasing reoperation rates issue,” Breast Cancer Research and Treatment, vol. 113, no. 2, by localization of neoplastic tissue in the resected area and pp. 397–402, 2009. thus, achieving R0 margins [21]. [8] J. Lee, H. Y. Park, W. W. Kim et al., “Clinical efcacy of In our study, although one patient (2.5%) was missed by intraoperative ultrasound for margin assessment in breast- IOUS and proved to have infltrated margins on the path- conserving surgery,” Breast Journal, vol. 26, no. 11, ological examination, another four patients (10%) were pp. 2308–2311, 2020. discovered by the same modality to have infltrated margins, [9] J. M. Chakedis, A. Tang, G. E. Kuehner et al., “Implementation and they were managed by re-excision in the same operative of intraoperative ultrasound localization for breast-conserv- setting. Although the failure rate was too low (2.5%), it is ing surgery in a large, integrated health care system is feasible expected to improve with the increased learning curve with and efective,” Annals of Surgical Oncology, vol. 28, no. 10, more US specimen examinations. pp. 5648–5656, 2021. [10] M. K. Hayes, “Update on preoperative breast localization,” Te current study has some limitations; being retro- Radiologic Clinics of North America, vol. 55, no. 3, pp. 591– spective in nature, along with its application in a single 603, 2017. medical center, are the main drawbacks. Tis should en- [11] J. H. Volders, M. H. Haloua, N. M. Krekel et al., “Intra- courage researchers to conduct more studies, including operative ultrasound guidance in breast-conserving surgery more patients from diferent oncological centers in the near shows superiority in oncological outcome, long-term cos- future. metic and patient-reported outcomes: fnal outcomes of a randomized controlled trial (COBALT),” European Journal of Surgical Oncology, vol. 43, no. 4, pp. 649–657, 2017. 4. Conclusions [12] N. M. Krekel, A. M. Lopes Cardozo, S. Muller, E. Bergers, Te application of IOUS has a signifcant benefcial impact S. Meijer, and M. P. van den Tol, “Optimising surgical ac- on the outcomes of BCS. It is associated with a marked curacy in palpable breast cancer with intra-operative breast ultrasound--feasibility and surgeons’ learning curve,” Euro- decline in positive resection margins, and its application pean Journal of Surgical Oncology, vol. 37, no. 12, pp. 1044– should be encouraged in the breast oncological practice. 1050, 2011. [13] H. Pan, N. Wu, H. Ding et al., “Intraoperative ultrasound Data Availability guidance is associated with clear lumpectomy margins for breast cancer: a systematic review and meta-analysis,” PLoS Te data used to support the fndings of this study are One, vol. 8, no. 9, Article ID e74028, 2013. available from corresponding authors upon request. [14] C. Eichler, A. Hubbel, ¨ V. Zarghooni et al., “Intraoperative ultrasound: improved resection rates in breast-conserving surgery,” Anticancer Research, vol. 32, no. 3, pp. 1051–1056, Conflicts of Interest [15] H. Eggemann, T. Ignatov, S. D. Costa, and A. Ignatov, Te authors declare that they have no conficts of interest. “Accuracy of ultrasound-guided breast-conserving surgery in the determination of adequate surgical margins,” Breast References Cancer Research and Treatment, vol. 145, no. 1, pp. 129–136, [1] A. S. Ibrahim, H. M. Khaled, N. N. Mikhail, H. Baraka, and [16] T. Vispute, V. Seenu, R. Parshad et al., “Comparison of re- H. Kamel, “Cancer incidence in Egypt: results of the national section margins and cosmetic outcome following intra- population-based cancer registry program,” J Cancer Epi- operative ultrasound-guided excision versus conventional demiol, vol. 2014, Article ID 437971, 2014. palpation-guided breast conservation surgery in breast can- [2] C. Coleman, “Early detection and screening for breast can- cer: a randomized controlled trial,” Indian Journal of Cancer, cer,” Seminars in Oncology Nursing, vol. 33, no. 2, pp.141–155, vol. 55, no. 4, pp. 361–365, 2018. [17] L. Barellini, M. Marcasciano, F. Lo Torto, A. Fausto, [3] R. A. da Costa Vieira, G. Biller, G. Uemura, C. A. Ruiz, and D. Ribufo, and D. Casella, “Intraoperative ultrasound and M. P. Curado, “Breast cancer screening in developing oncoplastic combined approach: an additional tool for the countries,” Clinics, vol. 72, no. 4, pp. 244–253, 2017. oncoplastic surgeon to obtain tumor-free margins in breast [4] Z. H. Sun, C. Chen, X. W. Kuang, J. L. Song, S. R. Sun, and conservative surgery-A 2-year single-center prospective W. X. Wang, “Breast surgery for young women with early- study,” Clinical Breast Cancer, vol. 20, no. 3, pp. e290–e294, stage breast cancer: mastectomy or breast-conserving ther- apy?” Medicine (Baltimore), vol.100, no.18, Article ID e25880, [18] M. M. Pop, S. Cristian, O. Hanko-Bauer, D. V. Ghiga, and R. Georgescu, “Obtaining adequate surgical margin status in [5] D. Aziz, E. Rawlinson, S. A. Narod et al., “Te role of reex- cision for positive margins in optimizing local disease control breast-conservation therapy: intraoperative ultrasound- guided resection versus specimen mammography,” Medicine after breast-conserving surgery for cancer,” Breast Journal, vol. 12, no. 4, pp. 331–337, 2006. and Pharmacy Reports, vol. 91, no. 2, pp. 197–202, 2018. International Journal of Surgical Oncology 5 [19] M. M. Moore, L. A. Whitney, L. Cerilli et al., “Intraoperative ultrasound is associated with clear lumpectomy margins for palpable infltrating ductal breast cancer,” Annals of Surgery, vol. 233, no. 6, pp. 761–768, 2001. [20] N. M. Krekel, M. H. Haloua, A. M. Lopes Cardozo et al., “Intraoperative ultrasound guidance for palpable breast cancer excision (COBALT trial): a multicentre, randomised controlled trial,” Te Lancet Oncology, vol. 14, no. 1, pp. 48–54, 2013. [21] O. Olsha, D. Shemesh, M. Carmon et al., “Resection margins in ultrasound-guided breast-conserving surgery,” Annals of Surgical Oncology, vol. 18, no. 2, pp. 447–452, 2011.

Journal

International Journal of Surgical OncologyHindawi Publishing Corporation

Published: Dec 7, 2022

There are no references for this article.