Intraoperative Imprint Cytology and Frozen Section Pathology for Margin Assessment in Breast Conservation Surgery: A Systematic Review

Abstract

Background Achieving negative surgical margins is critical to minimizing the risk of tumor recurrence in patients undergoing breast conservation surgery (BCS) for a breast malignancy. Our objective was to perform a systematic review comparing reexcision rates, sensitivity and specificity of the intraoperative use of the margin assessment techniques of imprint cytology (IC) and frozen section analysis (FSA), against permanent histopathologic section (PS). Methods The databases PubMed, Web of Knowledge, Cochrane Library and CINAHL Plus were searched for literature published from 1997 to 2011. Original investigations of patients who underwent BCS for breast cancer that evaluated margin assessment with PS and/or IC or FSA were included. Of 182 titles identified, 41 patient cohorts from 37 articles met inclusion criteria: PS (n = 19), IC (n = 7) and FSA (n = 15). Studies were summarized qualitatively using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for cohort studies and the Strength of Recommendation Taxonomy (SORT) numerical scale for diagnostic studies. Results The final reexcision rates after primary BCS were 35 % for PS, 11 % for IC (p = 0.001 vs. PS) and 10 % for FSA (p < 0.0001 vs. PS). For IC, reexcision rates decreased from 26 to 4 % (p = 0.18) and for FSA, reexcision rates decreased from 27 to 6 % (p < 0.0001). The pooled sensitivity of IC and FSA were 72 and 83 %. The pooled specificity of IC and FSA were 97 and 95 %. The average length of each technique was 13 min for IC and 27 min for FSA. Conclusions Patients who underwent BCS with intraop-erative IC or FSA to assess negative surgical margins had significantly fewer secondary surgical procedures for excision of their breast malignancies.

Reoperation Costs in Attempted Breast-Conserving Surgery: A Decision Analysis

“…Although no consensus on the optimal reoperation rate has been reached, several international bodies have, as noted earlier, suggested that reducing the number of repeat operations is a necessity [7][8][9] , with one organization suggesting 10% as a goal 9 . A number of institutional publications have reported reoperation rates close to that benchmark 1,8,34 , suggesting that it is achievable. However, any effort to move toward that goal has to take into account other considerations.…”

“…Reoperation rates are highly variable [1][2][3][4][5] , and although there is no evidence that re-excision is detrimental to overall survival 23 , it likely causes patient anxiety, increases surgical complication rates 24 , and contributes to poorer cosmetic results 10,25 . It might also delay the initiation of adjuvant chemotherapy.…”

Wide-field optical coherence micro-elastography for intraoperative assessment of human breast cancer margins

“…Such tools would enable the surgeon to more effectively remove all tumor during the initial surgery, hence reducing re-excision rates. A range of intraoperative techniques are currently used, including: frozen section analysis [8], imprint cytology [9], intraoperative specimen radiography [10] and intraoperative ultrasound [11]. However, these techniques are time consuming and reported positive margin rates using these techniques are greater than 20% [12].…”

Should Re-excision Lumpectomy Rates Be a Quality Measure in Breast-Conserving Surgery?

“…21,22 Finally, in a recent meta-analysis, the decision to utilize immediate intraoperative margin assessment also correlated with variability of RELR. 26 Esbona et al concluded that immediate intra-operative margin assessment with frozen section technique or touch prep cytology compared to no intra-operative pathological evaluation was associated with a lower RELR. 26 The primary motivation for re-excision after lumpectomy is to reduce cancer recurrence.…”

“…26 Esbona et al concluded that immediate intra-operative margin assessment with frozen section technique or touch prep cytology compared to no intra-operative pathological evaluation was associated with a lower RELR. 26 The primary motivation for re-excision after lumpectomy is to reduce cancer recurrence. Hence, re-excision of an ink positive margin represents good quality care because negative margins are associated with lower IBTR.…”