Evaluation of surgical margins by specimen in impalpable breast carcinoma: a radiopathological correlation

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1 Evaluation of surgical margins by specimen in impalpable breast carcinoma: a radiopathological correlation Poster No.: C-1146 Congress: ECR 2014 Type: Scientific Exhibit Authors: D. Mandich, L. Koren, T. Diaz de Bustamante, B. Sancho Perez, M. Arroyo, G. Ayala, D. Plata Ariza ; Madrid, Ma/ES, 2 Madrid/ES Keywords: Surgery, Mammography, Breast, Cancer DOI: /ecr2014/C-1146 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 32

2 Aims and objectives Non-palpable breast lesions are those not detectable at clinical examination given their small size, deep localization or consistency similar to normal parenchyma. These special characteristics make radiological tests essential in their detection, being identified in most cases in screening mammography and, less frequently, by ultrasound or MRI. Many of non-palpable lesions correspond to early stage cancers, for this reason biopsy is recommended in most cases. These lesions may have different appearances in mammography among which are nodules, microcalcifications, focal asymmetrical densities or architectural changes in the breast. In some cases, they can involve the whole quadrant or the entire breast keeping their non palpable characteristic even with biopsies showing infiltrating component. (Fig. 1) Promptly detection of early stage cancers has demonstrated a reduction in the mortality with the correct treatment up to 30%. It also allows conservative surgery in a higher number of patients. Long-term survival following breast-conserving therapy (BCT) has shown to be equivalent to that of mastectomy, also providing an acceptable cosmetic and psychological outcome and low morbidity. With the implementation of BCT a new challenge has emerged: to achieve appropriate surgical margins. Affected surgical margins occur in a range between 20% and 40% of the cases according to prior literature and are the strongest predictor of local recurrence. Various risk factors are reported in the literature to be associated with positive margins after lumpectomy. Most are related to tumor biology and patient characteristics and, hence, cannot be modified to improve surgical outcome. Some of them are patient age, tumor size, tumor grade, presence of multifocal or multicentric disease, coexisting ductal carcinoma in situ (Fig. 2), lobular histological type and positive axillary nodal status. Concerning to preoperative guidance techniques, X-ray wire-guided localization has more positive margins than ultrasound-guided localization (Fig. 3) presumably because the edges in tumors just identified by mammography are more indistinct and diffuse. Page 2 of 32

3 Mammographic findings related to affected margins are microcalcifications (Fig. 4) and dense breasts, probably because in these cases it is difficult to determine tumor's boundaries. In contrast to what happens with microcalcifications, the risk of positive surgical margin in other radiological appearances is not well known. (Fig 5 and Fig.6) However, it is presumable that lesions with an apparent border like nodules would present less affected margins than lesions with indistinct boundaries as architectural distortions or focal asymmetrical densities. The purpose of the present study is to evaluate if there is a relationship between the different radiologic presentations and the surgical margin positivity. Page 3 of 32

4 Images for this section: Fig. 1: 51-year-old patient with invasive ductal carcinoma. (a) Mediolateral oblique and (b) craniocaudal mammograms showed an architectural distortion in the outer quadrants transition of the right breast. Pathologic analysis revealed an invasive ductal carcinoma, with free edges in the surgical specimen. Page 4 of 32

5 Fig. 2: 59-year-old patient with focal asymmetrical density in the outer upper quadrant of right breast. (a) Right mediolateral oblique mammogram (b) US illustrated an irregular hypoechoic mass, not parallel to skin surface. (c) X-ray of the excised lump which includes the tumor transfixed by a wire. Pathologic analysis confirmed a ductal in situ carcinoma with negative surgical margins. Page 5 of 32

6 Fig. 3: 53-year-old patient with focal asymmetrical density in the right retroareolar region. Right (a) craniocaudal and (b) mediolateral oblique mammograms with nipple marking. (c) Directed US image identified hypoechoic and irregular mass not parallel to the skin surface. Ultrasound-guided localization was done. (d) Specimen radiography showed an ill-defined lesion without clear limits with wire marker next to the lesion. Pathologic analysis revealed an invasive ductal carcinoma with positive surgical margins. Page 6 of 32

7 Fig. 4: (a) Left craniocaudal mammogram with microcalcifications in the upper quadrants transition in a 56-year-old patient (orange circle). (b) Detail from image (a) showed a cluster of pleomorphic microcalcifications. Histopathologic evaluation of the lumpectomy specimen revealed invasive ductal carcinoma with negative surgical margins. Page 7 of 32

8 Fig. 5: 68-year- old patient with irregular mass at the outer upper quadrant of the left breast. Left (a) craniocaudal and (b) mediolateral oblique mammogram. (c) Specimen radiography showed the lesion transfixed by a localizing wire. Histopathological analysis revealed invasive ductal carcinoma with negative surgical margins. Page 8 of 32

9 Fig. 6: Spiculated mass in a 69-year-old patient (a) Craniocaudal and (b) mediolateral oblique mammograms of the left breast showed an irregular nodule with spiculated margins at the upper outer quadrant. Despite being a lesion with a visible border the histopathological analysis of surgical specimen revealed invasive ductal carcinoma with positive margins. Page 9 of 32

10 Methods and materials Fifty-four patients with breast carcinoma who underwent BCS at the Hospital 12 de Octubre in Madrid (Spain) in 2012 were the subject of this retrospective study. 52 of 54 patients (96%) had a mammography performed. 2 cases were diagnosed by ultrasound and were excluded from the analysis. We also excluded 3 patients with a false negative mammography. Mammographic findings were classified in nodules or masses (65.3%), density asymmetry (10,2%), microcalcifications (20,2%) and architectural distortion (4,1%) (Fig. 7,8,9,10 and 11). Fig. 12 References: Hospital Universitario 12 de Octubre, Madrid/SPAIN Page 10 of 32

11 As all the patients had breast cancer clinically occult, it was necessary to localize the tumor before surgical procedure (Fig. 13, 14 and 15). Most lesions were marked by wire-guided location (38/54). In this technique a wire is introduced in the tumor guided by mammography (34/54) or ultrasound (4/54). After resection, the excised specimen is evaluated mammographically to check if the lesion is completely included (Fig. 16). One case was examined with ultrasound during surgery to improve tumor assessment and, after surgery, the excised tissue was also examined using US to assess margin status. The rest of the patients were marked by ROLL (Radio-guided occult lesion localization) (16/54). In this technique, a nonspecific radioisotope is injected into the tumor under stereotactic or US guidance. The position of the primary tumor is assessed intraoperatively using a gamma probe. After excision of the tumor, the probe also can be used to search for any residual areas of high radioactivity (Fig. 17). Regarding of the surgical margins, there were 41 free edges (80%), 2 close margins, considering it when tumor cells are closer than 3 mm from the cut edge, and 6 positive margins, which means that tumor cells reach the edge. We counted close and positive margins as one making a 16,3% of margins affected. Page 11 of 32

12 Images for this section: Fig. 7: 41-year-old patient with architectural distortion in outer quadrants transition of right breast. (a) Bilateral craniocaudal mammograms showed an architectural distortion in the right outer quadrant (orange circle). (c) US showed a hypoechoic, irregular nodule with ill-defined margins and posterior acoustic shadowing. This lesion was marked before surgery by ultrasound guidance. Lumpectomy specimen revealed invasive ductal carcinoma. There were not affected margins in the surgical specimen. Page 12 of 32

13 Fig. 8: 69 -year-old patient. Scattered areas of fibroglandular density in breast (a) Craniocaudal and (b) mediolateral oblique mammogram of right breast showed a focal asymmetrical density in the outer lower quadrant. The lesion was located preoperatively by mammographic guidance with a wire marker. Histopathological evaluation of the lumpectomy revealed invasive ductal carcinoma with negative surgical margins. Page 13 of 32

14 Fig. 9: Focal asymmetrical density at the outer upper quadrant of left breast in a 55-yearold patient. (a) Left mediolateral oblique and (b) craniocaudal mammograms showed an opacity with indistinct margins. Histopathological lumpectomy examination revealed invasive ductal carcinoma with free edges. Page 14 of 32

15 Fig. 10: 70-year-old patient. Left (a) craniocaudal and (b) mediolateral oblique mammograms showed microcalcifications and focal asymmetrical density in the upper outer quadrant of the breast. (c) Specimen radiography showed a localising wire transfixing the focal asymmetrical density with microcalcifications. Histopathological evaluation of the lumpectomy specimen revealed invasive ductal carcinoma with positive margins. Page 15 of 32

16 Fig. 11: (a) Craniocaudal and (b) mediolateral oblique mammograms of the right breast in a 65 years-old patient showed an irregular nodule with spiculated margins at the upper outer quadrant. (c) Specimen radiography showed the lesion transfixed by a localizing wire. Histopathologic analysis of surgical specimen revealed invasive ductal carcinoma with positive margins,. Page 16 of 32

17 Fig. 12 Page 17 of 32

18 Fig. 13: (a) Ultrasound image of a 67-years-old patient with an irregular, ill-defined, hypoecoic mass located in the retroareolar region of right breast (b) Localizing wire placed in the middle of the mass by US guidance (c) Specimen radiography showed that the lesion is included. Pathologic analysis confirmed an invasive ductal carcinoma with positive surgical margins Page 18 of 32

19 Fig. 14: (a) Right craniocaudal mammogram of a 74-year-old patient with irregular mass at the lower inner quadrant of the right breast. (b) The lesion was identified preoperatively with wire marker placed by mammographic guidance. Pathological analysis confirmed an invasive ductal carcinoma with negative surgical margins. Page 19 of 32

20 Fig. 15: Right (a) craniocaudal and (b) mediolateral oblique mammograms showed a spiculated mass with microcalcifications at the outer upper quadrant of the right breast. (c) Mediolateral oblique mammogram with a wire within the lesion. Pathologic analysis confirmed an invasive ductal carcinoma with negative surgical margins. Page 20 of 32

21 Fig. 16: Right (a) craniocaudal and (b) mediolateral oblique mammogram showed clustered pleomorphic microcalcifications with no other abnormalities at the upper outer quadrant of right breast. (c) Specimen radiography showed microcalcifications and subtle focal density transfixed by a localising wire. Page 21 of 32

22 Fig. 17: 67-year-old patient with ill-defined mass in the retroareolar region of the right breast. Right (a) mediolateral oblique and (b) craniocaudal mammograms. The lesion was located for surgery by ROLL with ultrasound guidance. Histopathologic evaluation of lumpectomy revealed invasive ductal carcinoma with affected margins. Page 22 of 32

23 Results The results were that 16% of specimens with nodular lesions had affected margins (Fig. 18 and 19), a percentage slightly less than lesions with indistinct boundaries like asymmetrical density or microcalcifications, which had 20% of affected margins each. Fig. 20 References: UNIVERSITARIO 12 DE OCTUBRE - Madrid/ES Page 23 of 32

24 Fig. 21 References: UNIVERSITARIO 12 DE OCTUBRE - Madrid/ES Regarding the histological type, the majority of tumors were invasive ductal carcinoma 37 (75%), 6 (12,2%) were ductal carcinoma in situ (Fig. 22), and just 2 were invasive lobular carcinoma. If we are considering only the 8 patients with affected margins, 7 were IDC and only 1 was ILC. Owing to the small sample size in our study, it is not possible to establish a correlation between affected margins and histological type. Page 24 of 32

25 Images for this section: Fig. 18: (a) Left craniocaudal mammogram showed a nodule with irregular margins at the outer upper quadrant of the breast in a 50-year-old patient. (b) US image showed a small, hypoechoic nodule not parallel to the surface skin, with posterior acoustic shadowing. (c) Preoperative craniocaudal mammogram with a wire passing throw the lesion. Despite being a well-defined lesion the histopathological analysis of surgical specimen revealed invasive ductal carcinoma with affected margins. Page 25 of 32

26 Fig. 19: 43-year-old with spiculated mass at the outer quadrants transition of the right breast. Right (a) craniocaudal and (b) mediolateral oblique mammogram. (c) Specimen radiography showed the lesion transfixed by a localizing wire. Some spicules were near the edges but the hystopathological analysis revealed negative surgical margins. Page 26 of 32

27 Fig. 20 UNIVERSITARIO 12 DE OCTUBRE - Madrid/ES Page 27 of 32

28 Fig. 21 UNIVERSITARIO 12 DE OCTUBRE - Madrid/ES Page 28 of 32

29 Fig. 22: (a) Left craniocaudal mammogram with focal asymmetrical density at the inner lower quadrant of the left breast. (b) Mediolateral oblique mammogram with a wire marker transfixing the lesion. Pathological analysis revealed ductal carcinoma in situ with negative surgical margins Page 29 of 32

30 Conclusion Adequate surgical margins in breast-conserving therapy increase overall survival in patients with early-stage breast carcinoma. In our study, diffuse lesions as architectural distortion and microcalcifications showed a slightly more positive margins in surgical specimen in comparison with nodular lesions. Probably these results have not significant association due to few cases reviewed; nevertheless this trend makes it interesting to extend the study to a more representative sample in the future. Page 30 of 32

31 Personal information Author: Danitza Mandich Crovetto Page 31 of 32

32 References 1. Medina Fernández FJ, Ayllón MD, Lombardo MS, Rioja P, Basuñana G, Rufián S. Los márgenes de resección en la cirugía conservadora del cáncer de mama. Cirugía Española, Volumen 91, Issue 7, Rubio-Marína D, Muñoz JM, Rubio-Martínez J, de la Fuente-Pérez P. Lesiones no palpables de mama: correlación radiopatológica Clin Invest Gin Obst 2004;31(3): Saadai P, Moezzi M, Menes T. Preoperative and intraoperative predictors of positive margins after breast- conserving surgery: A retrospective review. Breast Cancer. 2011;18: Britton PD, Sonoda LI, Yamamoto AK, Koo B, Soh E, Goud A. Breast surgical specimen radiographs: how reliable are they?. Eur J Radiol Aug;79(2): Rubio IT, Marco V. The importance of surgical margins in conservative surgery for breast cancer. Cir Esp. 2006;79:3-9. Page 32 of 32