Influence of surgical technique on mastectomy and reexcision rates in breast-conserving therapy for cancer.

Introduction. Breast conserving surgery (BCS) requires tumor excision with negative margins. Reexcision rates of 30-50% are reported. Ultrasound localization, intraoperative margin pathology, and specimen mammography have reduced reexcisions, but require new equipment. Cavity shave margin (CSM) is a technique, utilizing existing equipment, that potentially reduces reexcision. This study evaluates CSM reexcision impact. Methods. 522 cancers treated with BCS were reviewed. Patients underwent standard partial mastectomy (SPM) or CSM. Data collected included demographics, pathology, and treatments. Results. 455 SPMs were compared to 67 CSMs. Analysis revealed no differences in pathology, intraductal component, or neoadjuvant chemotherapy. Overall reexcision rate = 43%. Most reexcisions were performed for DCIS at margin. SPMs underwent 213 reexcisions (46.8%), versus 16/67 (23.9%) CSMs (P = 0.0003). Total mastectomy as definitive procedure was performed after more SPMs (P = 0.009). Multivariate analysis revealed CSM, % DCIS, tumor size, and race to influence reexcisions. Conclusions. CSM is a technique that reduces reexcisions and mastectomy rates.

Volume of excision and cosmesis with routine cavity shave margins technique.

BACKGROUND: Cavity shave margin (CSM) removal is a surgical technique that reduces re-excision rates. One criticism of this technique has been that negative margins are obtained primarily as a result of higher volumes of tissue removed. This study evaluates the volume of tissue removed in a group that underwent CSM versus one that underwent standard partial mastectomy (SPM) and explores cosmetic outcomes. METHODS: Single-institution retrospective review identified 533 patients with a diagnosis of breast cancer who underwent PM. Matched pair analysis of 72 patients who had undergone PM with CSM versus 72 who had undergone SPM was performed. Volumes were calculated from dimensions in the pathology report. A subgroup was analyzed by a multidisciplinary panel for cosmetic outcome using the Harvard Breast Cosmesis Grading Scale. RESULTS: Mean tumor size in the CSM group was 1.52 versus 1.51 cm(3) in the SPM (P = 0.8073). Mean total volume of tissue excised with CSM was lower than that in the SPM group. Mean volume of excision with CSM was 80.66 and 165.1 cm(3) in the SPM group (P = 0.0005). Patients undergoing CSM required fewer re-excisions than the SPM group: 13 (18.1%) versus 25 (34.6%) (P = 0.03). Mean score for cosmesis was 2.3 in the CSM group and 3.0 for SPM (P = 0.0004). CONCLUSIONS: CSM decreases the need for re-excision. Total tissue volume excised is lower in patients who undergo CSM, and cosmetic results appear to be improved. This approach should be considered for all patients undergoing PM.

Impact of routine cavity shave margins on breast cancer re-excision rates.

PURPOSE: Breast-conserving therapy (BCT) is an accepted method of treating early breast cancer. We hypothesized that routine excision of additional cavity shave margins (CSM) at time of initial partial mastectomy reduces the need for additional surgery. METHODS: A single-institution retrospective review was performed of women, 18 years or older, with a new diagnosis of breast cancer who underwent partial mastectomy between 1 January 2004 and 1 October 2009. Five hundred thirty-three charts were reviewed. Of those, 69 patients underwent CSM at time of initial operation. These 69 patients were matched with patients who had undergone partial mastectomy without CSM by tumor size, presence of extensive intraductal component, and primary histology. RESULTS: The two groups were well matched for age, nuclear grade, associated lymphovascular invasion (LVI), receptor status, and multifocality. We found that 31.9% (44/138) required return to the operating room (OR) for re-excision of margins. Rate of return to the OR was 21.7% (15/69) in the CSM group and 42.0% (29/69) in the matched group (p = 0.011). Multivariate analysis found factors significantly associated with need for additional operation included lack of CSM (odds ratio 9.2, 95% CI 2.8-30.5, p = 0.0003), larger extent of intraductal component (odds ratio 7.0, 95% CI 1.8-27.0, p = 0.005), and lack of directed re-excision (odds ratio 6.4, 95% CI 1.7-25.1, p = 0.007). CONCLUSIONS: CSM at time of initial partial mastectomy decreases rate of re-excision by as much as ninefold. CSM should be considered at time of initial operation to reduce the need for subsequent reoperation.

Discriminative stimulus effects of 1-(2,5-dimethoxy-4-methylphenyl)-2-aminopropane (DOM), ketanserin, and (R)-(+)-{alpha}-(2,3-dimethoxyphenyl)-1-[2-(4-fluorophenyl)ethyl]-4-pipidinemethanol (MDL100907) in rats.

Very little is known about constitutive activity in vivo. This study examined whether constitutive activity and inverse agonism contribute to discriminative stimulus effects of drugs acting at serotonin (5-HT)(2A) receptors. Rats were trained to discriminate between saline and either 0.56 mg/kg 5-HT(2) receptor agonist 1-(2,5-dimethoxy-4-methylphenyl)-2-aminopropane (DOM), 1.0 mg/kg 5-HT(2A) receptor antagonist ketanserin, or 0.1 mg/kg purported 5-HT(2A) receptor inverse agonist (R)-(+)-alpha-(2,3-dimethoxyphenyl)-1-[2-(4-fluorophenyl)ethyl]-4-pipidinemethanol (MDL100907). Discriminative control was established with each drug after 33 to 35 sessions. MDL100907 and ketanserin did not occasion DOM lever responding but attenuated the discriminative stimulus effects of DOM. DOM did not occasion responding on the drug-associated lever in rats discriminating MDL100907 or ketanserin, but attenuated the discriminative stimulus effects of both drugs. Ketanserin and ritanserin occasioned MDL100907-lever responding, whereas rats discriminating ketanserin responded only partially on the drug-associated lever after receiving MDL100907, ritanserin, or the alpha(1)-adrenergic antagonist prazosin. Combining prazosin with MDL100907 or ritanserin resulted in near-complete ketanserin-lever responding, indicating that the ketanserin stimulus involves both 5-HT(2A) and alpha(1)-adrenergic receptors. Administration of p-chlorophenylalanine methyl ester, then fenfluramine, significantly decreased cortical 5-HT, enhanced sensitivity to the discriminative stimulus effects of DOM, and occasioned partial MDL100907-lever responding. Collectively, these results show that DOM and MDL100907 discriminative stimulus effects are mediated by 5-HT(2A) receptors and that ketanserin discriminative stimulus effects involve both 5-HT(2A) and alpha(1)-adrenergic receptors. Results in 5-HT-depleted rats further suggest that the discriminative stimulus effects of MDL100907 might involve antagonism of endogenous 5-HT and/or inverse agonism at 5-HT(2A) receptors.