Department of Gynecology and Obstetrics, University of Heidelberg, Heidelberg, Germany.
Universitätsfrauenklinik, INF 440, 69120, Heidelberg, Germany.
Breast Cancer Res Treat. 2022 Feb;191(3):589-598. doi: 10.1007/s10549-021-06466-3. Epub 2021 Dec 8.
This is the first study to systematically evaluate the diagnostic accuracy of intraoperative specimen radiography on margin level and its potential to reduce second surgeries in patients treated with neoadjuvant chemotherapy.
This retrospective study included 174 cases receiving breast conserving surgery (BCS) after neoadjuvant chemotherapy (NACT) of primary breast cancer. Conventional specimen radiography (CSR) was performed to assess potential margin infiltration and recommend an intraoperative re-excision of any radiologically positive margin. The histological workup of the specimen served as gold standard for the evaluation of the accuracy of CSR and the potential reduction of second surgeries by CSR-guided re-excisions.
1044 margins were assessed. Of 47 (4.5%) histopathological positive margins, CSR identified 9 correctly (true positive). 38 infiltrated margins were missed (false negative). This resulted in a sensitivity of 19.2%, a specificity of 89.2%, a positive predictive value (PPV) of 7.7%, and a negative predictive value (NPV) of 95.9%. The rate of secondary procedures was reduced from 23 to 16 with a number needed to treat (NNT) of CSR-guided intraoperative re-excisions of 25. In the subgroup of patients with cCR, the prevalence of positive margins was 10/510 (2.0%), PPV was 1.9%, and the NNT was 85.
Positive margins after NACT are rare and CSR has only a low sensitivity to detect them. Thus, the rate of secondary surgeries cannot be significantly reduced by recommending targeted re-excisions, especially in cases with cCR. In summary, CSR after NACT is inadequate for intraoperative margin assessment but remains useful to document removal of the biopsy site clip.
这是第一项系统评估新辅助化疗后保乳手术（BCS）术中标本放射摄影术在评估切缘水平方面的诊断准确性及其降低接受新辅助化疗的患者进行二次手术的可能性的研究。
本回顾性研究纳入了 174 例接受新辅助化疗（NACT）后原发性乳腺癌保乳手术的患者。常规进行标本放射摄影术（CSR）以评估潜在的切缘浸润情况，并建议对任何放射学阳性切缘进行术中再次切除。标本的组织学检查结果作为评估 CSR 准确性和 CSR 指导下再次切除降低二次手术可能性的金标准。
评估了 1044 个切缘。在 47 个（4.5%）组织学阳性切缘中，CSR 正确识别了 9 个（真阳性）。38 个浸润性切缘漏诊（假阴性）。这导致了 19.2%的敏感性、89.2%的特异性、7.7%的阳性预测值（PPV）和 95.9%的阴性预测值（NPV）。通过 CSR 指导的术中再次切除，将二次手术的比例从 23 例降低至 16 例，CSR 指导的术中再次切除的治疗需要数（NNT）为 25。在 cCR 患者亚组中，阳性切缘的患病率为 10/510（2.0%），PPV 为 1.9%，NNT 为 85。
NACT 后的阳性切缘很少见，CSR 检测切缘的敏感性较低。因此，通过推荐有针对性的再次切除并不能显著降低二次手术的比例，尤其是在 cCR 的情况下。总之，NACT 后的 CSR 不能满足术中切缘评估的要求，但仍有助于记录活检部位夹的切除情况。
