Case report – Intraoperative margin assessment of large breast specimens
B. Nakad, P.Simovici, D.Milevsky, A. Brodsky
Bothaina Nakad – Email: bthnnakad@gmail.com ORCID ID https://orcid.org/0000-0003-3224-8839 Surgery Department, Bnai-Zion Medical Center, Haifa, Israel Paula Simovici – Email: Paula.Simovitz@b-zion.org.il Radiology Department, Bnai-Zion Medical Center, Haifa, Israel Daria Milevsky – Email: danielmilevsky@yahoo.com Surgery Department, Bnai-Zion Medical Center, Haifa, Israel Asia Brodsky – Email: asiabrodsky@gmail.com Surgery Department, Bnai-Zion Medical Center, Haifa, Israel
Abstract We present here a case of the utility of Tomosynthesis in real time during surgery for margin assessment. This vigorous planning of operative steps allows one-step procedure with maximal outcome.
Introduction The current intraoperative margin evaluation methods used routinely are not adequate. Frozen sections of all suspected margins are not feasible specifically in a big specimen due to longer operating time and more difficult association with the correct orientation of the margins (1). The use of Margin probe has not been proven to have a clinical significance and increases the False-Positive rates of positive margins (2).
Methods A 40 years old patient, with Infiltrative Ductal Carcinoma, ERP PRN HER2P KI67 9% and cN1, with a complete clinical response post Neoadjuvant Herceptin-Perjeta, was planned for a left Mastectomy with oncoplastic reconstruction. A revision of all pre-NAC and post-NAC imaging, including a breast MRI and Tomosynthesis, revealed multiple areas in the breast with calcifications, in proximity to the skin. The proximity and distance of these foci of calcifications were measured, and for those less than 1 cm from the skin, a total of four foci, we used a skin-mark localization. Accordingly, the oncoplastic stages of the operation were planned with planned incisions in the skin.
Intraoperatively and after resection of the breast, the mastectomy specimen was evaluated using Tomosynthesis with an orientation system of margins in accordance with the anatomical orientation of the breast (Cranial, Medial and Lateral). One additional margin resection was decided on in real-time by the breast radiologist and breast surgeons, the medial border due to proximity of calcifications to the actual margin. There was no need for additional resections in the anterior margin, including the skin.
Results The final pathology was high-grade DCIS. The only close margin less then 2 mm was the lower medial margin, which was resected during surgery after imaging evaluation. This allowed complete resection of areas marked pre-surgery and confirmed intra-operatively by specimen Tomosynthesis.
Conclusion The use of real-time Tomosynthesis allowed our patient to undergo a one-step operation of mastectomy and a tissue expander with highly satisfactory oncologic and cosmetic outcomes.