publication date: Sep. 27, 2019

Trials & Tribulations

Reducing re-excisions

How intraoperative 3-D specimen tomosynthesis ensures fewer repeat breast cancer surgeries 

Roshni Rao

By Roshni Rao

Chief, Breast surgery program,
New York-Presbyterian/Columbia University Medical Center Associate professor of surgery, Columbia University Medical Center


This year in the United States, nearly 270,000 women will receive the devastating news that they have breast cancer.  Many will choose breast-conserving surgery, commonly referred to as lumpectomy, wherein the surgeon seeks to remove the malignant tumor, while also preserving as much healthy breast tissue as possible.

 It is a well-established fact that lumpectomy has long been the gold standard of surgical breast cancer care, particularly for women with early-stage disease. It is a far less invasive procedure with a shorter recovery time compared to what patients experience with a mastectomy, in which the entire breast is removed. And according to research, when followed by radiation, lumpectomy yields the same survival rate.  

Although lumpectomy is the best option for many breast cancer patients, with 170,000 procedures performed annually, it is not perfect. All too often, a post-operative pathology report shows that while the surgeon may have removed the entire tumor, a second surgical procedure is needed to clean up lingering cancer cells. Known as re-excision, it occurs in roughly 20% to 25% of cases, on average.

When removing a breast tumor, surgeons strive for clean margins. That means targeting not only the tumor, but also excising the surrounding ring of tissue. A pathologist declares the margins clean if no cancer cells are found at the outer edge of that tissue. It is not as simple as it sounds. How much tissue needs to be removed to ensure a healthy margin has been the subject of considerable debate. Some tumors are difficult to see or feel, which makes them hard to locate during surgery. Localization clips and guidewires inserted into the breast to mark the tumor’s location can be difficult to place, and in some cases, can shift position. Still, clean margins are critical to the efficacy of a lumpectomy. Studies show the likelihood of cancer reoccurring is twice as high when doctors fail to achieve adequate margins. Hence, the need for additional surgeries.

But with one in five lumpectomy cases returning to the operating room, the re-excision rate in the U.S. should be lower. It is critical for surgeons and their patients to have access to the latest innovations, once demonstrated effective by clinical research, be used wherever and whenever possible.

Re-excision costs patients, both financially and emotionally. Patients face additional financial burdens, prolonged recovery and heightened anxiety. Scared and frustrated, some women, when faced with a second trip to the operating room, opt for a mastectomy.

As with any surgical procedure, the skill and experience of the surgeon matters greatly, but so does the technology available in the operating room. Re-excision rates can vary wildly from doctor to doctor, and hospital to hospital. So, various medical facilities have highlighted techniques and technologies to reduce second surgeries.

For my practice, intraoperative 3-D specimen tomosynthesis imaging technology has had a profound impact on how surgeries are performed and the results that are achieved.

The technology is already familiar to patients and practitioners as the standard of care in mammography for breast cancer screening. Studies show that 3-D imaging finds more cancer than the traditional 2-D mammograms and reduces the number of false positives. Now, 3-D tomography has radically streamlined breast cancer surgery by allowing surgeons to better visualize the breast and affected area, even through dense breast tissue, in the operating room. With this sort of real-time, actionable information at our fingertips, surgeons can perform more efficiently and deliver better outcomes.

It’s like the difference between using an iPhone or relying on dial-up Internet from the 1990s.

Data presented by researchers at the UT Southwestern Medical Center in Dallas during the annual meeting of the American Society of Breast Surgeons in May showed that using 3-D tomography in the operating room reduces re-excision rates by more than 50% compared to the traditional 2-D imaging systems commonly in use.

It also saves time. Surgeons no longer need to wait for tissue samples to be delivered to the radiology and pathology departments for examination, a process that a decade ago routinely took 30 to 40 minutes. So, patients spend less time under anesthesia.

Unfortunately, some hospitals may balk, given the fine line between what’s best for the patient and the realities of health care economics. The health care system rewards us for performing more, not fewer surgeries. New technologies are expensive, and this one reduces the need for a surgical procedure that costs between $9,000 and $16,000.

But in the fight against cancer, a single cell can spell the difference between a full recovery or something quite different. Perfection, though impossible, should remain the goal of every breast cancer surgeon. Patients demand the best from their cancer care team, and this includes the most advanced surgical techniques and technologies available.

Copyright (c) 2020 The Cancer Letter Inc.