Top

Published in:

01-04-2019 | Breast Cancer | Breast Oncology

Minimally Invasive Intact Excision of High-Risk Breast Lesions and Small Breast Cancers: The Intact Percutaneous Excision (IPEX) Registry

Authors: Pat Whitworth, MD, Steven Schonholz, MD, Rogsbert Phillips, MD, Yara Robertson, MD, Antonio Ruiz, MD, Susan Winchester, MD, Cathy Graham, MD, Jean Simpson, MD, Chloe Wernecke, BA

Published in: Annals of Surgical Oncology | Issue 4/2019

Abstract

Background

Aiming to minimize overtreatment of high-risk breast lesions (HRLs), including atypical ductal hyperplasia, and small breast cancers, including ductal carcinoma in situ (DCIS), we investigated a minimally invasive (MI) approach to definitive diagnosis and management of these conditions.

Methods

In the prospective Intact Percutaneous Excision registry study, women aged 31–86 years had removal of small invasive cancers, DCIS, or HRLs using image-guided 12–20 mm radiofrequency basket capture (MI excision). Second-pass 20 mm basket capture obtained shaved margins in cancer patients. Standard imaging (specimen, breast) and histologic criteria were applied. Patient data were registered in an Institutional Review Board approved, Health Insurance Portability and Accountability Act-compliant registry.

Results

Of 282 registered patients, 124 had DCIS (n = 52) or invasive cancer (n = 72) and 160 had HRLs. Among cancer patients, 101 (81%) had clear histologic margins [average lesion size was 11 mm for both invasive cancers (4–20 mm) and DCIS (1.5–20 mm)]; 29 patients had re-excision (six despite clear margins). Among 160 HRLs, two were upgraded to DCIS and had MI excision. Two other HRL patients had subsequent standard surgical excision (no cancer found).

Conclusion

For diminutive HRLs, DCIS, and invasive cancers, MI excision can achieve the same procedure goals as standard surgical excision. Because MI excision removes less tissue with small incisions, it may reduce the discomfort and expense associated with standard treatment.

Brem RF, Lechner MC, Jackman RJ, et al. Lobular neoplasia at percutaneous breast biopsy: variables associated with carcinoma at surgical excision. Am J Roentgenol. 2008;190:637–41.CrossRef

Strigel RM, Eby PR, Demartini WB, Gutierrez RL, Allison KH, Peacock S, et al. Frequency, upgrade rates, and characteristics of high-risk lesions initially identified with breast MRI. Am J Roentgenol. 2010;195:792–8.CrossRef

Hartmann LC, Degnim AC, Santen RJ, Dupont WD, Ghosh K. Atypical hyperplasia of the breast—risk assessment and management options. N Engl J Med. 2015;372(1):78–89.PubMedPubMedCentralCrossRef

Eby PR, Ochsner JE, DeMartini WB, Allison KH, Peacock S, Lehman CD. Frequency and upgrade rates of atypical ductal hyperplasia diagnosed at stereotactic vacuum-assisted breast biopsy: 9- versus 11-gauge. Am J Roentgenol. 2009;192:229–34.CrossRef

Hogue JC, Morais L, Provencher L, et al. Characteristics associated with upgrading to invasiveness after surgery of a DCIS diagnosed using percutaneous biopsy. Anticancer Res. 2014;34(3):1183–91.PubMed

Sim YT, Litherland J, Lindsay E, et al. Upgrade of ductal carcinoma in situ on core biopsies to invasive disease at final surgery: a retrospective review across the Scottish Breast Screening Programme. Clin Radiol. 2015;70(5):502–6.PubMedCrossRef

Jackman RJ, Birdwell RL, Ikeda DM. Atypical ductal hyperplasia: can some lesions be defined as probably benign after stereotactic 11-gauge vacuum-assisted biopsy, eliminating the recommendation for surgical excision? Radiology 2002;224(2):548–54.PubMedCrossRef

Rao A, Parker S, Ratzer E, Stephens J, Fenoglio M. Atypical ductal hyperplasia of the breast diagnosed by 11-gauge directional vacuum-assisted biopsy. Am J Surg. 2002;184(6):534–7.PubMedCrossRef

Welch HG, Prorok PC, O’Malley AJ, Kramer BS. Breast cancer tumor size, overdiagnosis, and mammography screening effectiveness, N Engl J Med. 2016;375(15):1438–47.PubMedCrossRef

10.

Cortesi L, Chiuri VE, Ruscelli S, et al. Prognosis of screen-detected breast cancers: results of a population based study. BMC Cancer. 2006;6:17.PubMedPubMedCentralCrossRef

11.

Shaevitch, D, Taghipour S, Miller AB, Montgomery N, Harvey B. Tumor size distribution of invasive breast cancers and the sensitivity of screening methods in the Canadian National Breast Screening Study. J Cancer Res Ther. 2017;13(3):562–9.PubMed

12.

Allgood PC, Duffy SW, Kearins O, et al. Explaining the difference in prognosis between screen-detected and symptomatic breast cancers. Br J Cancer. 2011;104(11):1680–5.PubMedPubMedCentralCrossRef

13.

Whitworth PW, Simpson JF, Poller WR, et al. Definitive diagnosis for high-risk breast lesions without open surgical excision: the Intact Percutaneous Excision Trial (IPET). Ann Surg Oncol. 2011;18:3047.PubMedCrossRef

14.

Moran MS, Schnitt SJ, Giuliano AE, et al. Society of Surgical Oncology–American Society for Radiation Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in stages I and II invasive breast cancer. Ann Surg Oncol. 2014;21(3):704–16.PubMedCrossRef

15.

Morrow M, Van Zee KJ, Solin LJ, et al. Society of Surgical Oncology–American Society for Radiation Oncology–American Society of Clinical Oncology Consensus Guideline on Margins for Breast-Conserving Surgery with Whole-Breast Irradiation in Ductal Carcinoma in Situ. Pract Radiat Oncol. 2016;6(5):287–95.PubMedPubMedCentralCrossRef

16.

Hughes KS, Schnaper LA, Bellon JR, et al. Lumpectomy plus tamoxifen with or without irradiation in women age 70 years or older with early breast cancer: long-term follow-up of CALGB 9343. J Clin Oncol. 2013;31(19):2382–7.PubMedPubMedCentralCrossRef

17.

Society of Surgical Oncology. Don’t routinely use sentinel node biopsy in clinically node negative women ≥ 70 years of age with hormone receptor positive invasive breast cancer. Available at: http://www.choosingwisely.org/clinician-lists/sso-sentinel-node-biopsy-in-node-negative-women-70-and-over/. Accessed 10 Oct 2018.

18.

Martelli G, Miceli R, Daidone MG, Vetrella G, Cerrotta AM, Piromalli D, et al. Axillary dissection versus no axillary dissection in elderly patients with breast cancer and no palpable axillary nodes: results after 15 years of follow-up. Ann Surg Oncol. 2011;18(1):125–33.PubMedCrossRef

19.

Jørgensen KJ, Gøtzsche PC, Kalager M, Zahl PH. Breast cancer screening in Denmark: a cohort study of tumor size and overdiagnosis. Ann Intern Med. 2017;166(5):313–23.PubMedCrossRef

20.

Esserman LJ, Thompson IM Jr, Reid B. Overdiagnosis and overtreatment in cancer: an opportunity for improvement. JAMA. 2013;310(8):797–8.PubMedCrossRef

21.

Pace LE, Keating NL. A systematic assessment of benefits and risks to guide breast cancer screening decisions. JAMA. 2014;311(13):1327–35.PubMedCrossRef

22.

Chagpar AB, Killelea BK, Tsangaris TN. A randomized, controlled trial of cavity shave margins in breast cancer. N Engl J Med. 2015;373;503–10.PubMedPubMedCentralCrossRef

23.

Morrow M, Harris JR, Schnitt SJ. Surgical Margins in Lumpectomy for breast cancer—bigger is not better. N Engl J Med. 2012;367:79–82.PubMedCrossRef

24.

Fine RE, Boyd BA, Whitworth PW, Kim JA, Harness JK, Burak WE. Percutaneous removal of benign breast masses using a vacuum-assisted hand-held device with ultrasound guidance. Am J Surg. 2002;184;332–6.PubMedCrossRef

25.

Fine RE et al. (2003) Low-risk palpable breast masses removed using a vacuum-assisted hand-held device. Am J Surg. 186(4):362–7.PubMedCrossRef

26.

Bruening W, Fontanarosa J, Tipton K, Treadwell JR, Launders J, Schoelles K. Systematic Review: Comparative effectiveness of core-needle and open surgical biopsy to diagnose breast lesions. Ann Intern Med. 2010;152:238-246.PubMedCrossRef

27.

Killebrew LK, Oneson RH. Comparison of the diagnostic accuracy of a vacuum-assisted percutaneous intact specimen sampling device to a vacuum-assisted core needle sampling device for breast biopsy: initial experience. Breast J. 2006;12(4):302–8.PubMedCrossRef

28.

Sie A, Frankel S, Killebrew L, et al. Comparison of the diagnostic accuracy of a vacuum-assisted percutaneous Intact specimen sampling device to 11 g vacuum-assisted core procedures for biopsy of breast cancer: a multi-center experience. Radiological Society of North America 2004 Scientific Assembly and Annual Meeting, 28 November–3 December 2004: Chicago IL. Available at: http://archive.rsna.org/2004/4405243.html. Accessed 5 Sep 2018.

Title: Minimally Invasive Intact Excision of High-Risk Breast Lesions and Small Breast Cancers: The Intact Percutaneous Excision (IPEX) Registry
Authors: Pat Whitworth, MD
Steven Schonholz, MD
Rogsbert Phillips, MD
Yara Robertson, MD
Antonio Ruiz, MD
Susan Winchester, MD
Cathy Graham, MD
Jean Simpson, MD
Chloe Wernecke, BA
Publication date: 01-04-2019
Publisher: Springer International Publishing
Keywords: Breast Cancer
Breast Cancer
Published in: Annals of Surgical Oncology / Issue 4/2019
Print ISSN: 1068-9265
Electronic ISSN: 1534-4681
DOI: https://doi.org/10.1245/s10434-019-07212-2

At a glance: The STEP trials

Springer Medicine

Minimally Invasive Intact Excision of High-Risk Breast Lesions and Small Breast Cancers: The Intact Percutaneous Excision (IPEX) Registry

Abstract

Background

Methods

Results

Conclusion

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 4/2019

Is FGFR2 a Suitable Target to Treat Scirrhous-Type Gastric Cancer?

Theory of Relativity for Posterosuperior Segments of the Liver

Penile Cancer Management in the United States: Regional Centers of Expertise are Needed!

High Mean Corpuscular Volume Predicts Poor Outcome for Patients With Gastroesophageal Adenocarcinoma

Should Multidisciplinary Treatment Differ for Esophageal Adenocarcinoma Versus Esophageal Squamous Cell Cancer?

Splenic Preservation Just Might Be Reasonable for Patients with Left-Sided Pancreatic Cancer