Answer
Lumpectomies may be performed with palpation guidance or with image guidance. Variations on the theme of image guidance include the following:
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Wire localization of nonpalpable image-detected lesions via ultrasonographic, stereotactic, or MRI guidance (see images below) (Go to Breast Biopsy With Needle Localization for complete information on this topic.) [5]
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Hematoma ultrasonographic guidance by the operating surgeon
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Radioactive seed localization; the specimen should be evaluated radiographically to confirm excision of the intended lesion before completion of the operation
See the images below.
This orthogonal (mediolateral) projection confirms the position of the needle to be placed beyond the cluster of microcalcification.
This specimen radiograph shows the wire and the localized speculated mass in situ, with a good excision margin.
Patients who undergo a lumpectomy for calcifications should always be advised to have a mammogram following their lumpectomy to establish definitively that all calcifications were removed successfully. This mammogram should be performed before the administration of any radiation therapy.
In general, 2 mm or greater is a reasonable definition of a clear margin. Patients with margin widths less than 2 mm are often advised to return to the operating room for reexcision to improve local recurrence rates. The rate of surgical reexcision after lumpectomy ranges from 20-60% in the published literature.
In a 2018 update of the American Society of Breast Surgeons’ guidelines for lowering lumpectomy reoperation rates, McEvoy et al reached the following conclusions [6] :
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Patients require complete preoperative imaging, but the choice of imaging modality depends on patient factors, the surgeon’s comfort level, and communication with the radiologist
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Minimally invasive breast biopsy is appropriate for breast cancer diagnosis
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The authors recommend that following the confirmation of breast cancer via minimally invasive biopsy and prior to the performance of a breast-conserving procedure, a multidisciplinary plan be devised
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With several methods of localizing nonpalpable cancers available, including the increasingly popular nonwire localization techniques, surgeons should employ the modality with which they are most comfortable
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Studies (primarily consisting of unadjusted, nonrandomized, retrospective reviews) indicate that in patients undergoing initial breast-conserving surgery, those who are treated with oncoplastic lumpectomy require reoperation for margin-associated reasons less often than do patients who undergo nononcoplastic lumpectomy; however, the oncoplastic patients may have higher rates of postoperative surgical site infection and reoperations for nonmargin-related causes
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It is essential to orient a specimen via any technique that enables the breast pathologist to orient all of the specimen’s sides during margin evaluation
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Multiple modalities exist for intraoperative specimen review, which requires communication between the breast surgeon and radiologist
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A 50% decrease in the reexcision rate can be achieved by using cavity shaves for margins
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Facilities that evaluate margins via routine intraoperative frozen section or imprint cytology have significantly lower reoperation rates following initial lumpectomies for cancer
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Evidence strongly indicates that reoperation rates can be reduced through compliance with the Society of Surgical Oncology (SSO)–American Society for Radiation Oncology (ASTRO) margin guidelines
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The achievement of higher breast conservation rates, lower reoperation rates, and better cosmetic outcomes may be encouraged though the use, in eligible patients, of oncoplastic lumpectomy (even in cases of large tumors) and/or neoadjuvant chemotherapy
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This mammogram shows a spiculated mass to be transfixed by the guidewire
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Grid technique of localization.
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This orthogonal (mediolateral) projection confirms the position of the needle to be placed beyond the cluster of microcalcification.
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This specimen radiograph shows the wire and the localized speculated mass in situ, with a good excision margin.
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Radical mastectomy defect.
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Inflammatory breast cancer.
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Advanced breast cancer.
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Metastatic breast cancer to the back.
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Nipple retraction due to breast cancer.
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Breast cancer. Lobular carcinoma in situ. Enlargement and expansion of lobule with monotonous population of neoplastic cells.
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Breast cancer. Lobular carcinoma in situ. Enlargement and expansion of lobule with monotonous population of neoplastic cells.
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Breast cancer. Infiltrating ductal carcinoma. Low-grade carcinoma with well-developed glands invading the fibrous stroma.
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Breast cancer. Intraductal carcinoma, comedo type. Distended duct with intact basement membrane and central tumor necrosis.
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Breast cancer. Intraductal carcinoma, noncomedo type. Distended duct with intact basement membrane, micropapillary, and early cribriform growth pattern.
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Breast cancer. Papillary carcinoma. Solid papillary growth pattern with early cribriform and well-developed thin papillary fronds.
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Breast cancer. Inflammatory carcinoma. Nests of tumor cells plugging dermal lymphatics.
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Breast cancer. Colloid (mucinous) carcinoma. Nests of tumor cells in pool of extracellular mucin.
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Breast cancer. Estrogen receptor, immunostain. Positive staining of tumor cell nuclei with monoclonal antibody to estrogen receptor.
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Breast cancer. Her-2/neu overexpression. Infiltrating carcinoma with strong membrane immunoreactivity representing Her-2/neu overexpression.
