The continued role of intraoperative assessment of the surgical margins in lumpectomy samples.

Abstract

Currently, breast conservation therapy that includes removal of the primary tumor of the breast by lumpectomy followed by adjunct radiation is a preferred treatment for majority of breast cancer patients.1,2 This practice, however, requires the ability to obtain negative lumpectomy margins to balance between optimal local control of the tumor and minimal tissue resection.3 Obtaining clear surgical margins are found to be important for local control as positive surgical margins increase local recurrence rate by at least twofold.4– 6 Studies have demonstrated that as positive surgical margins are associated with higher rate of local recurrence and the need for a second return to the operating room for the reexcision of positive margins, measures should be in place to avoid this process. In addition, it is critically important to follow the established national guidelines in respect to the accepted definition of an adequate margin. Based on 2014, and 2016 consensus statements offered by the Society of Surgical Oncology and the American Society of Radiation Oncology, adequate surgical margin is defined as no tumor at ink for invasive breast cancer and a 2mm tumorfree margin adequate for ductal carcinoma in situ.7,8 In order to avoid a second surgery and the associated cost and anxiety to breast cancer patients undergoing lumpectomy, it is important to consider providing an intraoperative assessment of surgical margins. This requires an accurate and costeffective rapid intraoperative technique that would evaluate surgical margins and allow for realtime reexcision to be perform if necessary.9,10 There are two alternatives to provide an intraoperative consultation. The most traditional approach has been the frozen section analysis. This approach has shown to minimize reoperation rates.11– 17 In a recent study reported by Racz et al.,18 the use of intraoperative frozen section pathologic evaluation of margins in patients undergoing lumpectomy has resulted in an extremely low reoperation rate of <2%. Similarly, in the study reported by Akrami et al.19 published in the current issue of The Breast Journal, the authors report the low rate of 2.3% positive surgical margins among 4843 patients enrolled in this study. The authors attribute the low rate of the positive margins in their study to the use of the intraoperative frozen section consultation in their practice. There is, however, a trend that has made the use of intraoperative consultation by frozen sectioning less frequent with dependence only on the final permanent section diagnosis of surgical margins. This may be the result of frozen sections being considered labor intensive, expensive and technically difficult to freeze and cut adipose tissue.20– 22