Journal of Surgical Oncology 2014;110:15–20

Intraoperative Assessment of Margins in Breast Conservative Surgery—Still in Use? MARC THILL, MD, PhD,1* KRISTIN BAUMANN,

2 MD, AND

JANA BARINOFF,

1 MD

1

Department of Gynecology and Obstetrics, Breast Center, AGAPLESION Markus Hospital, Frankfurt am Main, Germany 2 Department of Obstetrics and Gynecology, Breast Center, University Hospital Schleswig-Holstein, Lu¨beck, Germany

A positive margin in breast conserving surgery is associated with an increased risk of local recurrence. Failure to achieve clear margins results in re‐ excision procedures. Methods for intraoperative assessment of margins have been developed, such as frozen section analysis, touch preparation cytology, near‐infrared fluorescence optical imaging, x‐ray diffraction technology, high‐frequency ultrasound, micro‐CT, and radiofrequency spectroscopy. In this article, options that might become the method of choice in the future are discussed.

J. Surg. Oncol. 2014;110:15–20. ß 2014 Wiley Periodicals, Inc.

KEY WORDS: intraoperative margin assessment; breast conserving surgery; optical imaging; breast cancer; ductal carcinoma in situ

INTRODUCTION Breast cancer is the most common cancer in women worldwide. In Europe 430,000 new breast cancer cases are annually diagnosed, and the estimated number of new breast cancer cases for 2014 in Germany is 75,200 [1,2]. With the increasing use of screening programs, smaller, non‐palpable invasive breast cancers (IBC) are detected at earlier stages, and ductal carcinoma in situ (DCIS) accounts for up to approximately 20% of newly diagnosed primary breast cancer cases [3]. Most patients with early breast cancer receive surgical intervention as the first step of treatment, and breast conserving surgery (BCS) with radiation has been amply demonstrated to be as safe as mastectomy. This advance, the use of intraoperative radiation therapy (IORT), oncoplastic repair of large surgical defects, and the development of skin/nipple sparing techniques has led to the need for intraoperative information regarding the margin status. The challenge of BCS is to remove the primary tumor with clear (negative) margins. The negative‐margin rate after the initial operation depends on multiple factors, including cell type, tumor size, lymphovascular invasion (LVI), multifocality, and volumes of excision. Consequently, margin status is associated with local control of disease and is a prognostic factor for in‐breast recurrence (IBR) [4,5]. A positive margin results in a re‐ excision procedure which may have negative consequences, such as prolonged wound healing, postoperative infection, poor cosmetic outcome, increased financial cost, patient anxiety, and potential for non‐compliance with the recommendation for re‐excision. Historically, re‐excision rates have ranged from 31% to 46% [6–8] for DCIS alone and from 11% to 46% for IBC with DCIS [9–13]. The definition of what constitutes an adequate histological margin of excision has been the subject of much debate. However, with that question aside, tumor‐localizing techniques have been developed, such as radioguided occult lesion localization (ROLL), single‐photon emission computed tomography (SPECT), intraoperative ultrasound (IOUS), and guide‐wire localization (GWL). These techniques guide excision but work on a “macroscopic” level and give no information about cancer cells at the margin. The remainder of this article will focus on intraoperative technologies that assess the surgical margin on a “microscopic” level, such as frozen section analysis [14], touch preparation (imprint) cytology [15], near‐ infrared (NIR) fluorescence optical imaging [16], x‐ray diffraction [17],

ß 2014 Wiley Periodicals, Inc.

high‐frequency ultrasound [18], micro‐CT [19], and the MarginProbe1 system [20].

Frozen Section Analysis Frozen section (FS) analysis is a widely used technique for assessing margins, in which multiple frozen sections on the margins of the excised tissue are usually performed. During this technique the excised specimen is frozen, sliced, and microscopically analyzed [21,22]. However, FS analysis has many limitations. It is time consuming and only possible if a pathologist is located proximate to the operating room. With small tumors, there is concern that there will be too little tissue for adequate evaluation of the specimen and procurement of biomarkers. The technique is prone to sampling error, as the pathologist does not know from which regions of the excised specimen the FS examination should be performed. Furthermore, the detection of invasive lobular cancer or DCIS at surgical margins is not reliable. Finally, the use of FS in patients treated with neoadjuvant therapy is associated with high false‐negative rates [23]. Sensitivity rates for detecting residual disease with frozen section analysis have ranged from between 65% and 78%, whereas specificity rates have ranged between 98% and 100% [21,22,24]. FS has also been reported to lower re‐excision rates in BCS by 17–34% [21,22,24]. In conclusion, FS is a relatively safe, time consuming, technique that may be associated with reduced re‐excision rates but has limitations in

Conflict of interest statement: M. Thill has received speaker honoraria from Dune Medical. The authors have no relevant affiliation or financial involvement with any organization or entity with financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from the disclosed. *Correspondence to: Marc Thill, MD, PhD, Department of Gynecology and Obstetrics, Breast Center, AGAPLESION Markus Hospital, Wilhelm‐ Epstein‐Strasse 4, Frankfurt am Main 60431, Germany. Fax: þ49‐(0)69‐ 9533‐2733. E‐mail: [email protected] Received 9 February 2014; Accepted 5 April 2014 DOI 10.1002/jso.23634 Published online 24 May 2014 in Wiley Online Library (wileyonlinelibrary.com).

16

Thill et al.

the margin assessment for patients who have DCIS, invasive lobular breast cancer, or have had neoadjuvant treatment.

TABLE I. Optical Sources of Contrast in Breast Tissue (Mod. 46)

Source of contrast

DRS, NIR spectral FL Raman ESS imaging spectroscopy spectroscopy OCT

Touch Preparation (Imprint) Cytology Intraoperative touch preparation cytology (IOTPC) or “imprint cytology” has been utilized since the 1970s. Two methods are in use; the touch and the scrape methods of slide preparation. During touch preparation, a glass slide is touched on the specimen surface. With the scrape preparation, the surface of the tissue is scraped with a scalpel, and the tissue is transferred to a glass slide. In the largest series of using IOTPC, Klimberg et al. [15] reported on 428 patients, with an accuracy rate of 99%. A more recently published study with 396 patients showed a sensitivity of 88.6%, a specificity of 92.2%, and a correlation with paraffin‐embedded histology of 91.5% [14]. Further, Esbona et al. [25] reported a meta‐analysis including 41 patient cohorts from 37 published articles, in which the re‐excision rate was 11% with the use of imprint cytology and was 35% with the use of permanent histopathologic sections. In the published literature, sensitivity has ranged from 80% to 100% and specificity from 85% to 100% [15,25,26]. However, this method has some limitations: (i) only superficial cells are detected and no information of the margin width is provided; (ii) an experienced cytologist is required to avoid incorrect interpretations of the cytology due to drying artifact and cauterization; and (iii) it does not allow the distinction between DCIS and invasive cancer. To reduce the time commitment of the cytologist, automated intraoperative microscopy via touch prep technique has been developed and published [27], but the technique is still in experimental stages.

NEW HORIZONS Near‐Infrared Optical Imaging Optical breast imaging is a novel technique that uses near‐infrared (NIR) light to assess optical properties of tissue. When fluorescent probes are excited by NIR light, they emit photons at predefined wavelength ranges, detectable by an optical imaging system. Recently, significant progress has been made in the development of optical imaging systems and fluorescent contrast agents for clinical application [28]. Optical imaging systems and fluorescent contrast agents are already used in some clinical applications, such as indocyanin green (ICG) in sentinel node biopsy detection [29]. Several animal and clinical studies have demonstrated the potential use of near‐infrared fluorescence (NIRF) optical imaging in breast surgery [30,31]. Table I presents a summary of the optical tools that have been used to measure different constituents of breast tissue, in applications including diagnostic biopsy, margin assessment, and monitoring response to neoadjuvant chemotherapy. The sources of contrast in breast tissue that have been evaluated using optical tools are: scattering (fibroglandular content of breast tissue); lipid and carotenoid concentration (fatty content of the breast cancer tissue content); hemoglobin (tissue vascularity); and fluorescence (metabolism of cancer cells) [32]. Several studies in breast cancer using different optical imaging approaches have been done to evaluate surgical margins. Diffuse reflectance, fluorescence, and Raman spectroscopy have all been used to detect deposits of cancer cells at the surgical margins of excised breast cancers, with reports of sensitivities in the range of 80–85% and specificities in the range of 90–95% [33,34]. Optical coherence tomography analyzes scattering associated with increased cell density. Evaluations of surgical margins on ex vivo specimens have demonstrated sensitivity and specificity rates of 100% and 82% in small numbers of patients [35,36]. Furthermore, Wilke et al. used a quantitative diffuse reflectance spectral imaging technique and demonstrated the capability to image an entire tumor margin, which had yet to be demonstrated by previously published optical techniques [36]. Journal of Surgical Oncology

Oxy‐hemoglobin Deoxy‐hemoglobin Heme Beta‐carotene or carotenoids Lipids Water Scattering Collagen FAD NADH

Yes Yes

Yes Yes —

— — —

Yes

Yes

Yes Yes Yes

— — Yes Yes

— — —

Yes Yes Yes Yes Yes

DRS, diffuse reflectance spectroscopy; ESS, elastic‐scattering spectroscopy; NIR, near‐infrared; FL, fluorescence; OCT, optical coherence tomography.

NIRF optical imaging systems are safe and simple to operate but have limitations, primarily related to the intrinsic characteristics of light propagation through tissue and to background signals associated with fluorescence [16,31]. Before this technology can be routinely used in an operating room setting, studies must be performed to determine which factors affect the precision and accuracy of the mapping techniques.

High‐Frequency Ultrasound Another promising approach to provide intraoperative margin assessment is the use of high‐frequency (HF) ultrasound. Several studies have shown that ultrasonic wave propagation in tissues is strongly dependent on histological features including cell structure, cell number density, tissue microstructure, and tissue heterogeneity [37,38]. Therefore, ultrasound has the potential to differentiate between normal, benign, and malignant entities in breast tissue because of the different acoustic properties of altered cells and microstructures of the tissue [39]. Of specific relevance to margin assessment was the study by Jeong et al., who examined eight mastectomy specimens by using ultrasound transmission tomography from 2 to 10 MHz and the frequency dependent attenuation of the ultrasonic wave propagation to classify the tissue in the mastectomy specimens. The high spatial resolution of the scans (1 mm) permitted good correlation to pathology micrographs [40]. Several studies have shown that HF ultrasound is sensitive to changes in cell and tissue histology using in vitro and in vivo models [41,42]. A feasibility study for intraoperative assessment of shaved margins with HF ultrasound (20–80 MHz) on a small number of patients having BCS was recently published by Doyle et al. [18]. There was a correlation between the HF ultrasonic measurements from the margins, but measurement uncertainties and the small number of samples limited the robustness of their results. In conclusion, this method is still experimental and subsequent studies are essential to develop a consensus regarding this technique.

X‐Ray Diffraction X‐ray diffraction (XRD) is used to analyze the structure of crytalline substances by determining the atomic and molecular structure of materials. XRD has also been shown to be feasible in characterizing weakly ordered structures, such as breast tissue. Due to altered arrangements of collagen and a reduction of the residual adipose tissue component after tumor invasion of healthy tissue [43], it has been possible to discriminate between normal and cancerous tissues. X‐ray diffraction computed tomography (XRDCT) has been used to improve the characterization of histological parameters [44]. This technique has been of particular interest regarding intraoperative margin assessment, as Pani et al. have created a model diffraction micro‐CT system [17].

Intraoperative Breast Margin Assessment Micro‐Computed Tomography (Micro‐CT) Intraoperative specimen radiography is routinely used for margin evaluation after excision of wire‐localized lesions. However, this method relies on the relationship between the radiographically visible lesion and the surgical margin. Micro‐computed tomography (micro‐CT) potentially is a novel technology for intraoperative examination of breast tissue, especially for small specimens, with a spatial resolution possible of 50% over all clinical studies in both IBC and DCIS. The device integrates well in the OR environment, and measures consistently on all breast tissue specimens. However, it is an adjunctive tool and not a perfect solution. False‐positive (30%) and false‐negative measurements do occur. With false‐negatives the goal of avoiding a re‐operation is missed. From our own experience, the device should be used mainly for non‐palpable lesions. We recommend that surgeons begin using the device in patients with less dense tissue and with lesions not directly behind the nipple‐ areolar complex. For more extensive operations, such as oncoplastic surgery or immediate reconstruction, a sufficient intraoperative margin assessment would be useful, and as well as for operations using intraoperative radiotherapy (IORT) or accelerated partial breast irradiation (APBI) that may increase in the future [58].

Intraoperative Breast Margin Assessment

REFERENCES 1. Ferlay J, Autier P, Boniol M, et al.: Estimates of the cancer incidence and mortality in Europe in 2006. Ann Oncol 2007; 18:581–592. 2. Zentrum für Krebsregisterdaten des Robert Koch Instituts. Brustkrebs. In: Robert Koch Institute, editor. Krebs in Deutschland 2009/2010, Vol. 9. www.rki.de 2013. 3. Veronesi U, Luini A, Botteri E, et al.: Nonpalpable breast carcinomas: Long‐term evaluation of 1,258 cases. Oncologist 2010;15:1248–1252. 4. Morrow M, Strom EA, Bassett LW, et al.: Standard for breast conservation therapy in the management of invasive breast carcinoma. CA Cancer J Clin 2002;52:277–300. 5. McCready DR: Keeping abreast of marginal controversies. Ann Surg Oncol 2004;11:885887. 6. Meijnen P, Oldenburg HS, Peterse JL, et al.: Clinical outcome after selective treatment of patients diagnosed with ductal carcinoma in situ of the breast. Ann Surg Oncol 2008;15:235–243. 7. Dillon MF, Mc Dermott EW, O’Doherty A, et al.: Factors affecting successful breast conservation for ductal carcinoma in situ. Ann Surg Oncol 2007;14:1618–1628. 8. Dillon MF, Maguire AA, McDermott EW, et al.: Needle core biopsy characteristics identify patients at risk of compromised margins in breast conservation surgery. Mod Pathol 2008;21:39–45. 9. Ikeda T, Akiyama F, Hiraoka M, et al.: Surgical margin status as a cause of local failure after breast conserving therapy. Breast Cancer 1999;6:93–97. 10. Chagpar AB, Martin RC II, Hagendoorn LJ, et al.: Lumpectomy margins are affected by tumor size and histologic subtype but not by biopsy technique. Am J Surg 2004;188:399–402. 11. Kurniawan ED, Wong MH, Windle I, et al.: Predictors of surgical margin status in breast‐conserving surgery within a breast screening program. Ann Surg Oncol 2008;15:2542–2549. 12. McCahill LE, Single RM, Aiello Bowles EJ, et al.: Variability in reexcision following breast conservation surgery. JAMA 2012; 307:467–475. 13. Jeevan R, Cromwell DA, Trivella M, et al.: Reoperation rates after breast conserving surgery for breast cancer among women in England: Retrospective study of hospital episode statistics. BMJ 2012;345:e4505. 14. D’Halluin F, Tas P, Rouquette S, et al.: Intra‐operative touch preparation cytology following lumpectomy for breast cancer: A series of 400 procedures. Breast 2009;18:248–253. 15. Klimberg VS, Harms S, Korourian S: Assessing margin status. Surg Oncol 1999;8:77–84. 16. Sevick‐Muraca EM: Translation of near‐infrared fluorescence imaging technologies: Emerging clinical applications. Annu Rev Med 2012;63:217–231. 17. Pani S, Cook EJ, Horrocks JA, et al.: Characterization of breast tissue using energy‐dispersive X‐ray diffraction computed tomography. Appl Radiat Isot 2010;68:1980–1987. 18. Doyle TE, Factor RE, Ellefson CL, et al.: High‐frequency ultrasound for intraoperative margin assessments in breast conservation surgery: A feasibility study. BMC Cancer 2011;11: 444. 19. Tang R, Buckley JM, Fernandez L, et al.: Micro‐computed tomography (micro‐CT): A novel approach for intraoperative breast cancer specimen imaging. Breast Cancer Res Treat 2013; 139:311–316. 20. Thill M: MarginProbe1: Intraoperative margin assessment during beast conserving surgery by using radiofrequency spectroscopy. Expert Rev Med Devices 2013;10:301–315. 21. Olson TP, Harter J, Muñoz A, et al.: Frozen section analysis for intraoperative margin assessment during breast‐conserving surgery results in low rates of re‐excision and local recurrence. Ann Surg Oncol 2007;14:2953–2960. 22. Cabioglu N, Hunt KK, Sahin AA, et al.: Role for intraoperative margin assessment in patients undergoing breast‐conserving surgery. Ann Surg Oncol 2007;14:1458–1471. 23. Riedl O, Fitzal F, Mader N, et al.: Intraoperative frozen section analysis for breast‐conserving therapy in 1016 patients with breast cancer. Eur J Surg Oncol 2009;35:264–270. Journal of Surgical Oncology

19

24. Jorns JM, Visscher D, Sabel M, et al.: Intraoperative frozen section analysis of margins in breast conserving surgery significantly decreases reoperative rates: One‐year experience at an ambulatory surgical center. Am J Clin Pathol 2012;138:657–669. 25. Esbona K, Li Z, Wilke LG: Intraoperative imprint cytology and frozen section pathology for margin assessment in breast conservation surgery: A systematic review. Ann Surg Oncol 2012;19:3236–3245. 26. Klimberg VS, Westbrook KC, Korourian S: Use of touch preps for diagnosis and evaluation of surgical margins in breast cancer. Ann Surg Oncol 1998;5:220–226. 27. Cortes‐Mateos MJ, Martin D, Sandoval S, et al.: Automated microscopy to evaluate surgical specimens via touch prep in breast cancer. Ann Surg Oncol 2009;16:709–720. 28. Luker GD, Luker KE: Optical imaging: Current applications and future directions. J Nucl Med 2008;49:1–4. 29. Hirano A, Kamimura M, Ogura K, et al.: A comparison of indocyanine green fluorescence imaging plus blue dye and blue dye alone for sentinel node navigation surgery in breast cancer patients. Ann Surg Oncol 2012;19:4112–4116. 30. Aydogan F, Ozben V, Aytac E, et al.: Excision of nonpalpable breast cancer with indocyanine green fluorescence‐guided occult lesion localization (IFOLL). Breast Care (Basel) 2012;7: 48–51. 31. Tagaya N, Yamazaki R, Nakagawa A, et al.: Intraoperative identification of sentinel lymph nodes by near‐infrared fluorescence imaging in patients with breast cancer. Am J Surg 2008;195:850–853. 32. Bydlon TM, Barry WT, Kennedy SA, et al.: Advancing optical imaging for breast margin assessment: An analysis of excisional time, cautery, and patent blue dye on underlying sources of contrast. PLoS ONE 2012;7:e51418. 33. Keller MD, Majumder SK, Mahadevan‐Lansen A: Spatially offset Raman spectroscopy of layered soft tissues. Optics Letters 2009; 34:926–928. 34. Haka AS, Volynskaya Z, Gardecki JA, et al.: Diagnosing breast cancer using Raman spectroscopy: Prospective analysis. J Biomed Opt 2009;14:054023. 35. Nguyen FT, Zysk AM, Chaney EJ, et al.: Intraoperative evaluation of breast tumor margins with optical coherence tomography. Cancer Res 2009;69:8790–8796. 36. Nachabé R, Evers DJ, Hendriks BH, et al.: Diagnosis of breast cancer using diffuse optical spectroscopy from 500 to 1600 nm: Comparison of classification methods. J Biomed Opt 2011;16: 087010. 37. Wilke LG, Brown JQ, Bydlon TM, et al.: Rapid noninvasive optical imaging of tissue composition in breast tumor margins. Am J Surg 2009;198:566–574. 38. Mamou J, Oelze ML, O’Brien WD Jr, et al.: Extended three‐ dimensional impedance map methods for identifying ultrasonic scattering sites. J Acoust Soc Am 2008;123:1195–1208. 39. Doyle TE, Goodrich JB, Ambrose BJ, et al.: Ultrasonic differentiation of normal versus malignant breast epithelial cells in monolayer cultures. J Acoust Soc Am 2010;128:EL229–EL235. 40. Huang SW, Li PC: Ultrasonic computed tomography reconstruction of the attenuation coefficient using a linear array. IEEE Trans Ultrason Ferroelectr Freq Control 2005;52:2011–2022. 41. Jeong JW, Shin DC, Do SH, et al.: Differentiation of cancerous lesions in excised human breast specimens using multiband attenuation profiles from ultrasonic transmission tomography. J Ultrasound Med 2008;27:435–451. 42. Czarnota GJ, Kolios MC, Abraham J, et al.: Ultrasound imaging of apoptosis: High‐resolution non‐invasive monitoring of programmed cell death in vitro, in situ and in vivo. Br J Cancer 1999;81:520–527. 43. Brand S, Solanki B, Foster DB, et al.: Monitoring of cell death in epithelial cells using high frequency ultrasound spectroscopy. Ultrasound Med Biol 2009;35:482–493. 44. Oliveira OR, Conceicao ALC, Cunha DM, et al.: Identification of neoplasias of breast tissue using a powder diffractometer. J Radiat Res 2008;49:527–532. 45. Alkhateeb SM, Abdelkader MH, Bradley DA, et al.: Breast tissue contrast‐simulating materials using energy‐dispersive X‐ray diffraction. Appl Radiat Isot 2012;70:1446–1450.

20

Thill et al.

46. Ritman EL: Current status of developments and applications of micro‐CT. Annu Rev Biomed Eng 2013;13:531–552. 47. Gufler H, Franke FE, Wagner S, et al.: Fine structure of breast tissue on micro computed tomography a feasibility study. Acad Radiol 2011;18:230–234. 48. Tang R, Coopey SB, Buckley JM, et al.: A pilot study evaluating shaved cavity margins with micro‐computed tomography: A novel method for predicting lumpectomy margin status intraoperatively. Breast J 2013;19:485–489. 49. Lue N, Kang JW, Yu CC, et al.: Portable optical fiber probe‐based spectroscopic scanner for rapid cancer diagnosis: A new tool for intraoperative margin assessment. PLoS ONE 2012;7:e30887. 50. Kennedy S, Geradts J, Bydlon T, et al.: Optical breast cancer margin assessment: An observational study of the effects of tissue heterogeneity on optical contrast. Breast Cancer Res 2010;12:R91. 51. Mohs AM, Mancini MC, Singhal S, et al.: Handheld spectroscopic device for in vivo and intraoperative tumor detection: Contrast enhancement, detection sensitivity, and tissue penetration. Anal Chem 2010;82:9058–9065. 52. Joines WT, Zhang Y, Li C, et al.: The measured electrical properties of normal and malignant human tissues from 50 to 900 MHz. Med Phys 1994;21:547–550. 53. Thill M, Baumann K: New technologies in breast cancer surgery. Breast Care (Basel) 2012;7:370–376.

Journal of Surgical Oncology

54. Pappo I, Spector R, Schindel A, et al.: Diagnostic performance of a novel device for real‐time margin assessment in lumpectomy specimens. J Surg Res 2009;160:277–281. 55. Allweis TM, Kaufman Z, Lelcuk S, et al.: A prospective, randomized, controlled, multicenter study of a real‐time, intraoperative probe for positive margin detection in breast‐conserving surgery. Am J Surg 2008;196:483–489. 56. Schnabel F, Tafra L, The MarginProbe Study group: A randomized, prospective multicenter study of the impact of intraoperative margin assessment with adjunctive use of MarginProbe vs. standard of care. 34th Annual San Antonio Breast Cancer Symposium, 2011; San Antonio, TX, USA. 57. Thill M, Dittmer C, Baumann K, et al.: MarginProbe(1)—Final results of the German post‐market study in breast conserving surgery of ductal carcinoma in situ. Breast 2014;23:94–96. 58. Boolbol SK, Cocilovo C, Tafra L: and the MarginProbe Study Group. Reduced positive margins for DCIS using a novel device. ASCO Breast Cancer Symposium 2011; San Francisco, CA, USA. 59. Vaidya JS, Wenz F, Bulsara M, et al.: Risk‐adapted targeted intraoperative radiotherapy versus whole‐breast radiotherapy for breast cancer: 5‐year results for local control and overall survival from the TARGIT‐A randomised trial. Lancet 2013;pii: S0140‐ 6736(13)61950‐9. doi: 10.1016/S01406736(13)61950‐9.