Development of intraoperative assessment of margins in breast conserving surgery: a narrative review

Abstract

Objective: We intend to provide an informative and up-to-date summary on the topic of intraoperative assessment of margins in breast conserving surgery (BCS). Conventional methods as well as cutting-edge technologies are analyzed for their advantages and limitations in the hope that clinicians can turn to this for reference. This review can also offer guidance for technicians in the future design of intraoperative margin assessment tools.Background: Achieving negative margins during BCS is one of the vital factors for preventing local recurrence. Conducting intraoperative margin assessment can ensure negative margins to a large extent and possibly relieve patients of the anguish of re-interventions. In recent years, innovative methods for margin assessment during BCS are advancing rapidly. And there is a lack of summary regarding the development of intraoperative margin assessment in BCS.Methods: A PubMed search with keywords "intraoperative margin assessment" and "breast conserving surgery" was conducted. Relevant publications were screened manually for its title, abstract and even full text to determine its true relevance. Publications on neo-adjuvant therapy and intraoperative radiotherapy were excluded. References from the searched articles and other supplementary articles were also looked into.Conclusions: Conventional methods for margin assessment yields stable outcome but its use is limited because of the demand on pathology staff and the trade-off between time and precision. Conventional imaging techniques pass the workload to radiologists at the cost of a significantly low duration of time.Involving artificial intelligence for image-based assessment is a further improvement. However, conventional imaging is inherently flawed in that occult lesions can't show on the image and the showing ones are ambiguous and open to interpretation. Unconventional techniques which base their judgment on cellular composition are more reassuring. Nonetheless, unconventional techniques should be subjected to clinical trials before putting into practice. And studies regarding comparison between conventional methods and unconventional methods are also needed to evaluate their relative efficacy.

Specimen mammography for intraoperative margin assessment in breast conserving surgery: a meta-analysis

“…Intraoperative pathological and imaging methods are the two main methods for intraoperative margin assessment in BCS 41 . Intraoperative pathological methods mainly include frozen section, touch smear, and imprint cytology, which all have high sensitivity, specificity, and accuracy 42 .…”

“…Other important limitations of intraoperative specimen mammography are: (1) specimen mammography is a two-dimensional imaging method which is inherently flawed in depicting three-dimensional specimens comprehensively 41 ; (2) because of the poor soft tissue contrast, the difficulty in determining the margin status using specimen mammography increases with the breast density 49 .…”

Updates and Debate Concerning Margin Adequacy and Management following Breast-Conserving Surgery

“…To reduce the reintervention rate after BCS, it is imperative to better determine the type of intervention preoperatively, as well as to adopt some intraoperative shrewdness [99,100]. For better planning of breast surgery, magnetic resonance imaging (MRI) has been widely applied with encouraging results, by lowering the re-excision rate after BCS [101] and by prompting an appropriate upgrade to mastectomy in a considerable number of cases, when warranted for cancer extent [102,103].…”

Effectiveness of Carbon Localization for Invasive Breast Cancer: An Institutional Experience

“…The incidence of BC varies greatly from one region to another depending on various risk factors, increases in life expectancy, and improvements in BC screening programs [ 3 ]. Improved screening strategies and early diagnosis of BC have increased the detection of hidden nonpalpable lesions [ 4 ], which are mostly often detected at an early stage and eligible for breast-conserving surgery (BCS) [ 5 ]. Since the 1990s, BCS followed by radiotherapy has become a new standard surgical procedure for these tumors, and, concomitantly, the management of BC has evolved towards the de-escalation of surgical treatment.…”

“…To perform BCS, all cancerous tissues should be resected while preserving as much healthy tissue as possible to maintain good aesthetic outcomes and enhance patient satisfaction [ 5 ]. However, to respect these two criteria, precise localization of the tumor is necessary and a good intraoperative margin assessment technique is needed to ensure that the entire tumor is resected to avoid additional interventions [ 4 ].…”