Sylvie D. Cornacchi

Systematic review of radioguided surgery for non-palpable breast cancer.

BACKGROUND This systematic review examines whether radioguided localization surgery (RGL) (radioguided occult lesion localization - ROLL and radioguided seed localization - RSL) for non-palpable breast cancer lesions produces lower positive margin rates than standard wire-guided localization surgery. METHODS We performed a comprehensive literature review to identify clinical studies using either ROLL or RSL. Included studies examined invasive or in situ BC and reported pathologically assessed margin status or specimen volume/weight. Two reviewers independently assessed study eligibility and quality and abstracted relevant data on patient and surgical outcomes. Quantitative data analyses were performed. RESULTS Fifty-two clinical studies on ROLL (n = 46) and RSL (n = 6) were identified. Twenty-seven met our inclusion criteria: 12 studies compared RGL to WGL and 15 studies were single cohorts using RGL. Ten studies were included in the quantitative analyses. Data for margin status and re-operation rates from 4 randomized controlled trials (RCT; n = 238) and 6 cohort studies were combined giving a combined odds ratio (OR) of 0.367 and 95% confidence interval (CI): 0.277 to 0.487 (p < 0.001) for margins status and OR 0.347, 95% CI: 0.250 to 0.481 (p < 0.001) for re-operation rates. CONCLUSIONS The results of this systematic review of RGL versus WGL demonstrate that RGL technique produces lower positive margins rates and fewer re-operations. While this review is limited by the small size and quality of RCTs, the odds ratios suggest that RGL may be a superior technique to guide surgical resection of non-palpable breast cancers. These results should be confirmed by larger, multi-centered RCTs.

The relationship between surgical factors and margin status after breast-conservation surgery for early stage breast cancer

BACKGROUND The studys aim was to identify technical factors that are predictive of negative margins after breast-conserving surgery (BCS). METHODS This was a retrospective, cohort study of patients who underwent BCS for early-stage cancer from 2000 to 2002. Pathological and specific surgical factors were compared with margin status. Univariate and multivariate regression analyses were performed. RESULTS Four hundred eighty-nine cases were reviewed. The positive margin rate after the initial surgery was 26%. In univariate analysis, lobular histology, size, grade, multifocality, and the presence of EIC and LVI were associated with positive margins (P < .05). The absence of cavity margin dissection and specimen orientation labeling, the absence of a confirmed diagnosis, and smaller volumes of excision were also associated with positive margins (P < .05). In multivariate analysis, confirmed diagnosis, small tumor size, ductal histology, absence of LVI and multifocality, palpability, cavity margin dissection, and larger volumes of excision were predictors of negative margins. CONCLUSIONS This study shows that specific surgical factors are predictive of margin status. Both tumor and technical factors should be considered when planning BCS.

A Prospective Evaluation of Positron Emission Tomography Scanning, Sentinel Lymph Node Biopsy, and Standard Axillary Dissection for Axillary Staging in Patients with Early Stage Breast Cancer

Background: Positron emission tomography (PET) is a noninvasive imaging modality that can detect malignant lymph nodes. This study determined the sensitivity, specificity, predictive values, and likelihood ratios of PET scanning compared with standard axillary lymph node dissection (ALND) and sentinel lymph node biopsy (SLNB) in staging the axilla in women with early stage breast cancer.Methods: Women with clinical stage I or II breast cancer had whole body PET scanning before ALND and SLNB, in a prospective, blinded protocol. ALND were evaluated by standard hematoxylin and eosin (H&E) staining techniques, while sentinel nodes were also examined for micrometastatic disease.Results: A total of 98 patients were recruited. PET compared with ALND demonstrated sensitivity of 0.40 (95% CI, 0.16, 0.68), specificity 0.97 (CI, 0.90, 0.99), positive likelihood ratio 14.4 (CI, 3.21, 64.5), positive predictive value 0.75 (CI, 0.35, 0.97), and false–negative rate of 0.60 (CI, 0.32, 0.84). Test properties were similar for PET compared with sentinel nodes positive by H&E staining. A few false–positive scans (0.028, CI, 0.003, 0.097) were seen. Multiple logistic regression analysis found that PET accuracy was better in patients with high grade and larger tumors. Increased size and number of positive nodes were also associated with a positive PET scan.Conclusions: The sensitivity of PET compared with ALND and SLNB was low, whereas PET scanning had high specificity and positive predictive values. The study suggests that PET scanning cannot replace histologic staging in early stage breast cancer. The low rate of false–positive findings suggests that PET can identify women who can forego SLNB and require full axillary dissection.

A prospective study of tumor and technical factors associated with positive margins in breast-conservation therapy for nonpalpable malignancy.

BACKGROUND The purpose of this study was to identify factors that predict an increased risk of a positive surgical margin after breast-conserving therapy for nonpalpable carcinoma of the breast. METHODS In this prospective study, 305 patients with nonpalpable invasive breast cancer or ductal carcinoma in situ were identified and underwent localization lumpectomy. Patient, technical, and tumor factors with a potential to predict margin status were documented. RESULTS A 20% positive margin rate was observed. Univariate analysis of patient, tumor, and technical factors revealed that localizations performed under stereotactic guidance (P < .001), presence of in situ disease, high tumor grade, larger tumor size, multifocal disease, and presence of mammographic microcalcifications (P < .02) were predictive of positive margins. With the exception of tumor grade and mammographic microcalcifications, multivariable analysis identified the same factors. CONCLUSIONS This study identified several factors associated with positive margins that should be considered when planning breast-conserving therapy for nonpalpable tumors.

Results of a Surgeon-Directed Quality Improvement Project on Breast Cancer Surgery Outcomes in South-Central Ontario

BackgroundGaps in breast cancer (BC) surgical care have been identified. We have completed a surgeon-directed, iterative project to improve the quality of BC surgery in South-Central Ontario.MethodsSurgeons performing BC surgery in a single Ontario health region were invited to participate. Interventions included: audit and feedback (A&F) of surgeon-selected quality indicators (QIs), workshops, and tailoring interviews. Workshops and A&F occurred yearly from 2005–2012. QIs included: preoperative imaging; preoperative core biopsy; positive margin rates; specimen orientation labeling; intraoperative specimen radiography of nonpalpable lesions; T1/T2 mastectomy rates; reoperation for positive margins; sentinel lymph node biopsy (SLNB) rates, number of sentinel lymph nodes; and days to receive pathology report. Semistructured tailoring interviews were conducted to identify facilitators and barriers to improved quality. All results were disseminated to all surgeons performing breast surgery in the study region.ResultsOver 6 time periods, 1,828 BC charts were reviewed from 12 hospitals (8 community and 4 academic). Twenty-two to 40 participants attended each workshop. Sustained improvement in rates of positive margins, preoperative core biopsies, specimen orientation labeling, and SLNB were seen. Mastectomy rates and overall axillary staging rates did not change, whereas time to receive pathology report increased. The tailoring interviews concerning positive margins, SLNB, and reoperation for positive margins identified facilitators and barriers relevant to surgeons.ConclusionsThis surgeon-directed, regional project resulted in meaningful improvement in numerous QIs. There was consistent and sustained participation by surgeons, highlighting the importance of integrating the clinicians in a long-term, iterative quality improvement strategy in BC surgery.

Users’ Guide to the Surgical Literature: Understanding confidence intervals

Increasingly, surgical research articles are citing confidence intervals (CIs) when reporting treatment effects. It is important to understand the theory behind CIs so that present and future surgical literature can be correctly interpreted and clinically useful information gained to help guide treatment decisions. The move toward including CIs is predominantly owing to them providing more information for the clinician regarding research results. In general, with p values, research results can be deemed statistically significant or not, whereas treatment effect and its corresponding CIs can give information regarding the magnitude of the difference between 2 treatments and the interval of values within which the true value is likely to be found.1 This provides information as to whether results are clinically important.2 To illustrate how CIs work, how to interpret them and how to critically appraise the validity of evidence using CIs of a treatment effect, a surgical problem and the critical appraisal of research findings are presented in this article.

How to assess a survey in surgery.

The use of surveys is expanding in all domains of society. Frequently surgeons are presented with hard-copy or email surveys asking for information about their knowledge, beliefs, attitudes and practice patterns. The purpose of these questionnaires may be to obtain an accurate picture of what is going on in their surgical practices, and results are used by local, regional or national organizations to effect changes in surgical practice. Questionnaires can collect descriptive (reporting actual data) or explanatory (drawing inferences between constructs or concepts) data and can explore several constructs at a time.1,2 There are 2 basic types of surveys: cross-sectional and longitudinal surveys. Some cross-sectional surveys gather descriptive information on a population at a single time (e.g., survey of orthopedic trauma surgeons to explore the influence of physician and practice characteristics on referral for physical therapy in patients with traumatic lower-extremity injuries3). A different cross-sectional survey questionnaire might be designed to determine the relation between 2 factors on a representative sample at a particular time. For example, a population-based cross-sectional survey was conducted to explore geographic and sociodemographic factors associated with variation in the accessibility of total hip and knee replacement surgery in England.4 The authors found evidence of unequal access based on age, sex, rurality and race. Longitudinal surveys are conducted to determine changes in a population over a period of time.5 An example is a prospective longitudinal survey on quality of life among 558 women with breast cancer who underwent surgical treatment and were compared according to whether or not they received chemotherapy.6 The authors reported that the quality of life of both groups improved significantly in the year after primary treatment ended, but adjuvant chemotherapy was associated with more severe physical symptoms. Note that prevalence rather than incidence is normally determined in a cross-sectional survey. On the other hand, the temporal sequence of a cause and effect relation can be assessed using longitudinal surveys. The aim of a survey is to obtain reliable and unbiased data from a representative sample.7 Surveys can have a major impact if surgical organizations act on the results. If the surveys have sound methodology, most likely their inferences are correct and will be helpful. However, if proper methodology was not considered and inferences are adopted, surveys can have undesired consequences. High response rates are needed to ensure validity and reduce nonresponse bias.1,2 Response rates to mail and email surveys are particularly low among surgeons, some as low as 9%.8–11 Response rates as high as 80% have also been reported.12,13 The purpose of this article is to help surgeons critically appraise survey results reported in the surgical literature.

Time-resolved fluorescence (TRF) and diffuse reflectance spectroscopy (DRS) for margin analysis in breast cancer: TRF AND DRS FOR MARGIN ANALYSIS IN BREAST CANCER

One of the major problems in breast cancer surgery is defining surgical margins and establishing complete tumor excision within a single surgical procedure. The goal of this work is to establish instrumentation that can differentiate between tumor and normal breast tissue with the potential to be implemented in vivo during a surgical procedure.

Adoption and outcomes of radioguided seed localization for non-palpable invasive and in-situ breast cancer at three academic tertiary care centers

INTRODUCTION Radioguided seed localization (RSL) is an alternative technique to wire-guided localization (WL) for localizing non-palpable breast lesions for breast conserving surgery. The purpose of this study was to assess adoption and outcomes of RSL at 3 academic hospitals in our city. METHODS Data for consecutive invasive and in-situ breast cancer cases localized with RSL or WL at 3 hospitals between January 2012 and February 2016 were abstracted. Data analysis was conducted using the Students t-test, ANOVA with Tukeys HSD test for post-hoc multiple comparisons, and chi-squared test. RESULTS There were 803 consecutive cases. Hospital 1 exclusively used RSL (247 cases), whereas H2 adopted RSL (109 cases), but continued to use WL (347 cases). Hospital 3 exclusively used WL (100 cases). There was no difference between RSL and WL groups in positive margin rate (p = 0.337), re-operation (p = 0.413), or mean specimen volume (p = 0.190). DISCUSSION There has been variable adoption of RSL in our city. Despite this, relevant surgical outcomes have been similar across groups. The causes of variable adoption of this novel technique merit further investigation.

Effects of a regional guideline for completion axillary lymph node dissection in women with breast cancer to reduce variation in surgical practice: A qualitative study of physicians' views

BACKGROUND Recently the impact of completion axillary lymph node dissection (cALND) after positive sentinel lymph node biopsy on significant outcomes has been questioned, leading to variation in surgical practice. To address this variation, a multidisciplinary working group created a regional guideline for cALND. We explored the views and experiences of surgeons, medical oncologists (MOs), radiation oncologists (ROs) in a qualitative study that examined guideline implementation in practice. METHODS The Pathman framework (awareness, agreement, adoption and adherence) informed the interview guide design and analysis. Semi-structured interviews were conducted with MOs, ROs and surgeons and transcribed. Transcripts were coded independently by 2 members of the study team and analyzed. Disagreements were resolved through consensus. RESULTS Twenty-eight physicians (5 MO; 6RO; 17S) of 41 (68% of those approached) were interviewed. Ten of 11 (91%) hospital sites (54% community; 46% academic) and all 4 cancer clinics within the region were represented. Twenty-seven physicians (96%) were aware of the guideline, with all physicians reporting agreement and general adherence to the guideline. Most physicians indicated nodal factors, age and patient preference were key components of cALND decision-making. Physicians from all disciplines perceived that the guideline helped reduce variation in practice across the region. There were concerns that the guideline could be applied rigidly and not permit individual decision-making. CONCLUSIONS Physicians identified breast cancer as an increasingly complex and multidisciplinary issue. Facilitators to guideline implementation included perceived flexibility and buy-in from all disciplines, while individual patient factors and controversial supporting evidence may hinder its implementation.