Diagnostic value of mobile digital specimen radiography in evaluation of breast cancer resection margins

Karcinom dojke predstavlja najčešću malignu neoplazmu među ženskom populacijom, a poštedna terapija dojke, preferirani je model lečenja bolesnica u ranom stadijumu bolesti. Smatra se da je optimalna hirurška resekciona margina 2 mm. Opisano je mnogo metoda koje služe za intraoperativnu proveru suficijentnosti resekcione hirurške margine i sve one imaju svoje prednosti i mane. Ciljevi ove studije bili su da se utvrdi, da li postoji statistički značajna razlika u određivanju širine negativne resekcione hirurške margine izražene u milimetrima pri operacijama karcinoma dojke upotrebom palpatorne metode i intraoperativne mobilne radiografije, poređenjem nalaza merenja hiruga sa većim i manjim iskustvom u hirurgiji karcinoma dojke kao i nalaza radiologa u odnosu na patohistološku ex tempore analizu. Istraživanje je sprovedeno kao retrospektivno–prospektivna studija na Klinici za operativnu onkologiju, Instituta za onkologiju Vojvodine i obuhvatilo je 150 bolesnica kod kojih je preoperativno dijagnostikovan karcinom dojke. Kriterijum za uključenje u studiju bilo je izvođenje poštedne operacije dojke sa ili bez disekcije ipsilaterale aksile, dok su iz studije isključene bolesnice kod kojih nije bilo moguće izvesti poštednu operaciju dojke, one sa radiološki potvrđenom diseminovanom bolešću, kao i bolesnice koje su ranije operisane zbog karcinoma iste dojke. Kod svih 150 ekstirpiranih karcinoma dojke urađena je procena širine resekcione hirurške margine intraoperativno palpatornom metodom, zatim na aparatu za mobilnu digitalnu radiografiju, te radiogram analiziran od strane iskusnog i manje iskusnog hiruga u hirurgiji karcinoma dojke, kao i radiologa te upoređen sa nalazom ex tempore patohistološke analize. Definitivna širina resekcione hirurške margine potvrđena je na parafinskim patohistološkim preparatima. Srednja vrednost praćenja bolesnica, postoperativno, iznosila je 100,97 nedelja. Najveći broj bolesnica pripadao je starijoj životnoj dobi (56,67%). Preoperativna lokalizacija klinički nepalpabilnih tumora u dojci urađena je kod 52 (34,67%) bolesnice. Najčešće se tumor prezentovao kao solitarni fokus sa okolnim ognjištima in situ karcinoma (72, 48%), dok je najčešći histološki subtip bio duktalni invazivni karcinom dojke (112 (74,67%)). Najveći broj operacija dojke okarakterisan je kao kvadrantektomija (85 (56,67)), dok je najučestalija operacija aksile bilo određivanje limfnog čvora stražara (119 (79,33%). Analizom rada aparata za mobilnu digitalnu radiografiju došli smo do saznanja da nema statistički značajne razlike u oceni kvaliteta radiograma i širine resekcione hirurške margine merene na aparatu za mobilnu digitalnu radiografiju između iskusnog hirurga i radiologa. Statistički značajna razlika nije uočena ni pri merenju širine resekcione hirurške margine izražene u milimetrima na aparatu za mobilnu digitalnu radiografiju od strane iskusnog hirurga i radiologa u odnosu na ex tempore patohistološku analizu, dok je ista uočena nakon definitivne patohistološke analize. Šansa doresekcije tkiva dojke nakon merenja na aparatu za mobilnu digitalnu radiografiju je 1,4 puta veća nego nakon patohistološke ex tempore analize. Lokalni recidiv javio se kod jedne pacijentkinje tokom perioda praćenja. Ne postoji statistički značajna razlika u određivanju širine resekcione hirurške margine izražene u milimetrima upotrebom aparata za mobilnu digitalnu radiografiju od strane iskusnog hirurga i radiologa u odnosu na patohistološku ex tempore analizu, dok ista postoji nakon analize radiograma od strane manje iskusnog hirurga. Palpatorna metoda se ne može smatrati sigurnom metodom u određivanju širine hirurške resekcione margine. Ne postoji statistički značajna razlika u broju doresekcije tkiva dojke između hirurga sa različitim hirurškim iskustvom.Breast cancer is the most common malignant neoplasm in the female population, and conservative breast therapy is the preferred treatment model for patients in early stages of the disease. The optimal surgical resection margin, from healthy breast tissue around the primary tumor is 2 mm. Many methods have been described that serve to check the resection margin during breast conservative surgery and all of them have their advantages and disadvantages. The aim of this study was to determine whether there was a statistically significant difference in the determination of the width of the negative resection margin expressed in millimeters in breast cancer surgery using palpatory method and intraoperative mobile specimen radiography, comparing the findings of measuring of surgeons with greater and lesser experience in breast cancer surgery as well as the findings of the radiologist in relation to histopathological ex tempore and definitive histopathological analysis. The study was conducted as a retrospective - prospective study at the Clinic for Operative Oncology, Oncology Institute of Vojvodina and included 150 patients who were preoperatively diagnosed with breast cancer. The criterion for inclusion in the study was the opportunity to perform breast conservative surgery with or without complete axillary lymph node dissection. Patients that were treated with breast amputation, those with radiological confirmed disseminated disease, as well as patients previously operated from cancer were excluded from the study. For all 150 extirpated breast cancers, an estimate of the width of the resection surgical margin was performed intraoperatively with a palpatory method, followed by measuring on device for mobile specimen digital radiography, and a radiogram was analyzed by an experienced and less experienced surgeon in breast cancer surgery, as well as by a radiologist and compared with an ex tempore histopathological analysis. The definitive width of the resection surgical margin was confirmed on histopathological preparations. The mean follow-up, postoperatively, was 100.97 weeks. The majority of patients belonged to the elderly age (56.67%). Preoperative localization of clinically impalpable breast tumors was performed in 52 (34.67%) patients. Most often the tumor was presented as a solitary focus with surrounding foci of in situ cancer (72, 48%), while the most common histological subtype was invasive ductal breast cancer (112 (74.67%)). The majority of breast operations were characterized like quadrantectomy (85 (56.67)), while the most frequent axillary surgery was the determination of the sentinel lymph node (119 (79.33%). No significant difference was observed in the evaluation of radiography quality and the width of the resection surgical margin measured on the mobile digital radiography device between the experienced surgeon and the radiologist. No statistically significant difference was observed in the measurement of the width of the resection surgical margin expressed in millimeters on the mobile digital radiography device by the experienced surgeon and radiologist versus ex tempore histopathological analysis, while the statistical difference was observed after definite histopathological analysis. The chance of breast tissue reexcision after measurement on a mobile digital radiography device is 1.4 times higher than after histopathological ex tempore analysis. Local relapse occurred in one patient during the follow-up period. There is no statistically significant difference in the determination of the width of the resection surgical margin expressed in millimeters using a mobile digital radiography device by an experienced surgeon in breast cancer surgery and radiologist with respect to histopathological ex tempore analysis. However, the statistical difference exists after radiogram analysis by a less experienced surgeon. The palpatory method cannot be considered as a safe method in determining the width of a surgical resection margin. There is no statistically significant difference in the number of breast tissue additional resections between surgeons with different surgical experience