The pancake phenomenon contributes to the inaccuracy of margin assessment in patients with breast cancer

doi:10.1016/S0002-9610(02)00902-9

The American Journal of Surgery

Volume 184, Issue 2, August 2002, Pages 89-93

https://doi.org/10.1016/S0002-9610(02)00902-9 Get rights and content

Abstract

Background: To determine the effect on margin evaluation for patients with breast cancer, we prospectively quantified the “flattening” of the breast specimen after surgical removal.

Methods: The volume and height of 100 consecutive breast biopsy specimens were recorded independently by the operating surgeon and the pathologist. Five factors were analyzed that were thought to contribute to changes in specimen dimensions: patient age, breast tissue density, mammographic lesion type, specimen size, and the use of compression during specimen radiography.

Results: After surgical removal, mean volume and height of the breast specimens decreased from 46 cm³ to 29 cm³ (30%) and from 2.6 cm to 1.4 cm (46%), respectively. Flattening of the breast specimens occurred in all subgroups studied.

Conclusions: Breast specimens are flattened after surgical removal, losing almost 50% of their original height. This “pancake” phenomenon has important implications for the accuracy of margin analysis.

Section snippets

Methods

Between October 31, 2000, and July 23, 2001, all patients undergoing needle localization for excision of impalpable breast lesions were entered into this study. After surgical excision of the involved tissue, the operating surgeon measured the length, width, and height of each specimen. The specimen was then placed on a flat tray and brought immediately to the mammography department for specimen radiography.

The original mammogram was reviewed in advance to determine whether compression was

Results

Ninety-six consecutive patients underwent 100 consecutive breast biopsies—specifically, needle localization and excision of impalpable breast lesions. The median age of the patients was 51 years (range 30 to 83). Two patients underwent simultaneous excision of two separate impalpable breast lesions. Two patients underwent sequential excision of an impalpable breast lesion after a failed biopsy. All procedures were performed by one of two dedicated breast surgeons.

The mean size of the original

Comments

The role of margin assessment remains critical in determining the outcome of patients with both in situ and invasive breast cancers treated with breast conservation therapy. Results from several recent studies have shown that positive microscopic margins are associated with a significantly higher rate of local recurrence than those with negative margins [8], [9], [10]. Moreover, the extent of margin involvement is similarly important, with recurrence being higher for patients with extensive

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Breast conserving surgery is the standard of care for early breast cancer, however in a quarter of patients, satisfactory margins are not achieved, usually leading to re-excision. Residual disease is found in less than half of these re-excisions, leading to increased morbidity, poorer cosmesis and increased cost, possibly with no oncological benefit. Our study aimed to identify a group of patients with unsatisfactory margins but a low risk of residual disease, who may be able to avoid re-excision.
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Citation Excerpt :
This value is higher than our R2 value of 0.026 for the minimal margin, but even an R2 value of 0.33 is still not useful for daily practice. This poor correlation between the radiographic and histopathological margin distances might be explained by the “pancake phenomena” of SR, which results in changes in specimen height and volume of up to 50% due to compression or gravity during SR [27,29,30]. The results of current study regarding the poor accuracy of SR in RSL in predicting margin status are also in accordance with the results reported in WGL studies.
To evaluate the diagnostic performance for margin assessment of specimen radiography (SR) in breast conserving surgery (BCS) using radioactive I¹²⁵-seed localization (RSL).
The clinical, radiographic and histopathological data of women who underwent BCS after pre-operative RSL with intraoperative SR during nine consecutive years were analyzed. The histological margin and radiographic margin outcomes on SR were compared and results of intraoperative re-excisions were investigated.
A consecutive series of 448 women with invasive carcinoma (n = 211), ductal carcinoma in situ (DCIS) (n = 79) and a combination of DCIS and invasive carcinoma (n = 158) were included. The median minimal margins for the radiological masses and microcalcifications measured on SR were 14 mm and 11 mm, respectively. Based on a radiological cut-off SR margin value of 1 mm, the overall sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were 21.0%, 95.0%, 26.0%, and 94.0%, respectively. The area under the receiver-operating curve was 0.73. Intraoperative re-excisions based on SR were performed in 31 (6.9%) patients; histopathological examination of the additional excised tissue revealed DCIS or invasive carcinoma in 6 (19.4%) patients. Hence, SR was beneficial for 6/448 patients (1.3%), and unnecessary intraoperative re-excisions were performed in 20/448 patients (4.5%). The number need to treat is 75; this implies that per 75-SR one resection with involved margins is prevented.
SR has a moderate diagnostic performance for margin involvement using RSL. A more accurate intraoperative margin assessment tool is warranted.

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Scientific paperThe pancake phenomenon contributes to the inaccuracy of margin assessment in patients with breast cancer

Abstract

Section snippets

Methods

Results

Comments

Int J Radiat Onclo Biol Phys

Int J Radiat Onclo Biol Phys

Hum Pathol

Int J Radiat Onclo Biol Phys

Int J Radiat Onclo Biol Phys

The consensus conference on the treatment of in situ ductal carcinoma of the breast, April 22-25, 1999

Semin Breast Dis

The influence of margin width on local control of ductal carcinoma in situ of the breast

N Engl J Med

Risk factors in breast conservation therapy

J Clin Oncol

Local failure and margin status in early-stage breast carcinoma treated with conservation surgery and radiation therapy

Ann Surg

Margin status and local recurrence after breast-conserving surgery

Arch Surg

Scientific paper
The pancake phenomenon contributes to the inaccuracy of margin assessment in patients with breast cancer