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Validated prediction model for positive resection margins in breast-conserving surgery based exclusively on preoperative data.

ABSTRACT: Positive margins after breast-conserving surgery (BCS) and subsequent second surgery are associated with increased costs and patient discomfort. The aim of this study was to develop a prediction model for positive margins based on risk factors available before surgery. Patients undergoing BCS for in situ or invasive cancer between 2015 and 2016 at site A formed a development cohort; those operated during 2017 in site A and B formed two validation cohorts. MRI was not used routinely. Preoperative radiographic and tumour characteristics and method of operation were collected from patient charts. Multivariable logistic regression was used to develop a prediction model for positive margins including variables with discriminatory capacity identified in a univariable model. The discrimination and calibration of the prediction model was assessed in the validation cohorts, and a nomogram developed. There were 432 patients in the development cohort, and 190 and 157 in site A and B validation cohorts respectively. Positive margins were identified in 77 patients (17.8 per cent) in the development cohort. A non-linear transformation of mammographic tumour size and six variables (visible on mammography, ductal carcinoma in situ, lobular invasive cancer, distance from nipple-areola complex, calcification, and type of surgery) were included in the final prediction model, which had an area under the curve of 0.80 (95 per cent c.i. 0.75 to 0.85). The discrimination and calibration of the prediction model was assessed in the validation cohorts, and a nomogram developed. The prediction model showed good ability to predict positive margins after BCS and might, after further validation, be used before surgery in centres without the routine use of preoperative MRI.Presented in part to the San Antonio Breast Cancer Symposium, San Antonio, Texas, USA, December 2018 and the Swedish Surgical Society Annual Meeting, Helsingborg, Sweden, August 2018.

SUBMITTER: Ellbrant J

PROVIDER: S-EPMC8493005 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:Intraoperative frozen-section analysis of the lumpect-omy margin during breast-conserving surgery (BCS) is an excellent method in obtaining a clear resection margin. This study aimed to investigate the usefulness of intraoperative circumferential frozen-section analysis (IOCFS) of lumpectomy margin during BCS for breast cancer, and to find factors that increase the conversion into mastectomy.From 2007 to 2011, 509 patients with breast cancer underwent IOCFS during BCS. The outer surfaces of the shaved lumpectomy margins were evaluated. A negative margin was defined as no ink on the tumor. All margins were evaluated using the permanent section analysis.Among the 509 patients, 437 (85.9%) underwent BCS and 72 (14.1%) finally underwent mastectomy. Of the 483 pathologically confirmed patients, 338 (70.0%) were true-negative, 24 (5.0%) false-negative, 120 (24.8%) true-positive, and 1 (0.2%) false-positive. Twenty-four patients (4.7%) among total 509 patients had undetermined margins as either atypical ductal hyperplasia or ductal carcinoma in situ in the first IOCFS. The IOCFS has an accuracy of 94.8% with 83% sensitivity, 99.7% specificity, 93.4% negative predictive value, and 99.2% positive predictive value. Sixty-three cases (12.4%) were converted to mastectomy, the first intraoperatively. Of the 446 (87.6%) patients who successfully underwent BCS, 64 patients received additional excisions and 32 were reoperated to achieve clear margin (reoperation rate, 6.3%). Twenty-three of the reoperated patients underwent re-excisions using the second intraoperative frozen section analysis, and achieved BCS. Nine cases were additionally converted to mastectomy. No significant differences in age, stage, and biological factors were found between the BCS and mastectomy cases. Factors such as invasive lobular carcinoma, multiple tumors, large tumor, and multiple excisions increased the conversion to mastectomy.The IOCFS analysis during BCS is useful in evaluating lumpectomy margins and preventing reoperation.

Project description:INTRODUCTION:Extracapsular extension (ECE) in regional lymph nodes and positive surgical margins (PSM) are considered high-risk adverse pathologic features in patients with oropharyngeal squamous cell carcinoma (OPSCC) that each constitute an indication for postoperative adjuvant chemoradiation. We identify pre-operative clinical factors that can predict post-operative ECE and/or PSM and create a nomogram to help clinical decision making. METHODS:Adult patients with non-metastatic OPSCC with initial surgical treatment and confirmed HPV status diagnosed between 2010 and 2014 were selected from the National Cancer Database. Clinical staging was modified to American Joint Committee on Cancer 8th edition parameters. Logistic regression was used for multivariate analysis to identify predictors of pathologic ECE and/or PSM. RESULTS:5065 patients were included. 47.5% of the 3336 HPV-positive (HPV+) patients had ECE/PSM. 40.4% of the 1729 HPV-negative (HPV-) patients with had ECE/PSM. A model was built that included age, clinical ECE, tumor grade, and clinical T and N staging for HPV+ patients. Increasing N-classification was highly predictive of pathologic ECE and/or PSM (N1 OR?=?3.6, N2 OR?=?7.0, N3 OR?=?11.2, p?<?0.01). Clinical ECE (OR?=?4.1, p?<?0.01), tumor grade (ORs 2.2-4.4 with p?<?0.05), and increasing clinical T-classification (ORs 1.2-1.8, p?<?0.05) were also associated with ECE and/or PSM. A similar model was built for HPV- with similar predictive capability. Two internally validated nomograms were designed that demonstrated good discrimination (HPV+ AUC?=?0.66, 95% CI: 0.64-0.68, and HPV- AUC?=?0.70, 95% CI: 0.67-0.72) and good calibration (goodness-of-fit statistic of HPV+ 6.32, p?=?0.61 and HPV- 11.66, p?=?0.17). CONCLUSIONS:These are the first nomograms designed to help predict ECE or PSM for both HPV+ and HPV- OPSCC. The nomograms can facilitate shared decision-making between clinicians and patients as they consider upfront treatment selection for OPSCC.

Project description:ImportanceThe 2014 publication of the Society of Surgical Oncology-American Society for Radiation Oncology (SSO-ASTRO) Consensus Guideline on Margins for Breast-Conserving Surgery recommended a negative margin definition of no ink on tumor. Adoption of this guideline would represent a major change in surgical practice that could lower the rates of reoperation.ObjectiveTo assess changes in reoperation rates after publication of the SSO-ASTRO guideline.Data sourcesA systematic search of Embase, PREMEDLINE, Evidence-Based Medicine Reviews, Scopus, and Web of Science for biomedical literature published from January 2014 to July 2019 was performed. This search was supplemented by web searches and manual searching of conference abstracts.Study selectionIncluded studies compared the reoperation rates in preguideline vs postguideline cohorts (actual change), retrospectively applied the SSO-ASTRO guideline to a preguideline cohort (projected change), or described the economic outcomes of the guideline.Data extraction and synthesisStudy characteristics and reoperation rates were extracted independently by 2 reviewers. Odds ratios (ORs) were pooled by random effects meta-analysis. Analyses were stratified by study setting (institutional or population) and preguideline accepted margins. The economic outcomes of the guideline were summarized narratively. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was followed.Main outcomes and measuresOdds ratios for postguideline vs preguideline reoperation rates.ResultsFrom 1114 citations, 30 studies (with 599 016 participants) reported changes in reoperation rates. Studies included a median (range) of 487 (100-521 578) participants, and 20 studies were undertaken in the US, 6 in the UK, 3 in Canada, and 1 in Australia. Among 21 studies of actual changes, pooled ORs showed a statistically significant reduction in reoperation, with an OR lower in institution-based studies than in population-based studies (OR, 0.62 [95% CI, 0.52-0.74] vs 0.76 [95% CI, 0.72-0.80]; P = .04 for subgroup differences). Among 9 studies of projected changes, the pooled OR was lower for preguideline margin thresholds of 2 mm or more compared with 1 mm (OR, 0.47 [95% CI, 0.40-0.56] vs 0.85 [95% CI, 0.79-0.91; P < .001 for subgroup differences). Projected changes were likely to overestimate actual changes. Six studies that estimated the postguideline economic outcome found the guideline to be potentially cost saving, with a median (range) saving of US $3540 ($1800-$25 650) per woman avoiding reoperation.Conclusions and relevanceThis study found a decrease in reoperation rates after the publication of the SSO-ASTRO guideline; this reduction was greater at an institutional level than a population level, the latter reflecting the differences in guideline adoption between centers. These early outcomes may be conservative estimates of longer-term implications.

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Validated prediction model for positive resection margins in breast-conserving surgery based exclusively on preoperative data.

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