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.