Surgical Margins Status Assessment After Breast Conserving Surgery: Is There a Difference Between Surgeon and Radiologist Evaluation?

Main Article Content

Alessandra Surace
Stephanie Gentile
Aurora Raponi
Giorgia Pasquero
Donatella Tota
Maria Grazia Baù


Breast cancer , Mammography, Intra-operative imaging, Faxitron, Lumpectomy


Background: The aim of this study is to evaluate the accuracy of intra-operative specimen mammography (ISM) in surgical margins status assessment and highlight the concordance between the interpretations of the surgeon and the radiologist.
Methods: Our cross-sectional study included 130 patients with early breast cancer, surgically treated between October 2013 and September 2017 in the multidisciplinary breast center of the A.O.U. City of Health and Science (which is a complex of several hospitals) in Turin, Italy. All recruited patients underwent breast conservative surgery. Surgical margins were evaluated intraoperatively, using intra-operative specimen mammography. A standard compression intra-operative specimen mammography was obtained by the surgeon using the dedicated radiological equipment (Faxitron®, BioVision). After the surgeon’s evaluation of the margins, Faxitron images were sent to PACS. All ISMs images were analyzed by the same specialized radiologist in remote access to confirm the surgeon evaluation. We used kappa formula to report concordance.
Results: The discordance rate of positive readings between the surgeon and the radiologist was 5.3% while that of negative readings was 6.9%. The concordance rate between radiologist and pathologist assessments was 100%. Intra-operative specimen mammography specificity was 94% (95% CI: 88–97), and sensitivity was 47% (95% CI: 38–56), with PPV found to be 53% (95% CI: 95% 44-62) and NPV determined to be 92% (95% CI: 86–96), when the assessment was made by the surgeon.
Conclusion: Intra-operative specimen mammography is a helpful tool to identify infiltrated margins and to reduce the rate of secondary surgeries by recommending targeted re-excisions of corresponding orientations in order to obtain a final negative margin status. In our experience, not only radiologists but also surgeons could correctly read Faxitron® intra-operative specimen mammography.


1. Agarwal S, Pappas L, Neumayer L, Kokeny K, Agarwal J. Effect of breast conservation therapy vs mastectomy on disease-specific survival for early-stage breast cancer. JAMA Surg. 2014; 149(3):267-74.
2. Chen K, Liu J, Zhu L, Su F, Song E, et al. Comparative effectiveness study of breast-conserving surgery and mastectomy in the general population: A NCDB analysis. Oncotarget. 2015;6(37):40127-40.
3. Fisher S, Gao H, Yasui Y, Dabbs K, Winget M. Survival in stage I-III breast cancer patients by surgical treatment in a publicly funded health care system. Ann Oncol. 2015;26(6):1161-9.
4. Hofvind S, Holen Å, Aas T, Roman M, Sebuødegård S, et al. Women treated with breast conserving surgery do better than those with mastectomy independent of detection mode, prognostic and predictive tumor characteristics. European Journal of Surgical Oncology. 2015;41(10):1417-22.
5. Hwang ES, Lichtensztajn DY, Gomez SL, Fowble B, Clarke CA. Survival after lumpectomy and mastectomy for early stage invasive breast cancer: the effect of age and hormone receptor status. Cancer. 2013;119(7):1402-11.
6. Kurian AW, Lichtensztajn DY, Keegan TH, Nelson DO, Clarke CA, et al. Use of and mortality after bilateral mastectomy compared with other surgical treatments for breast cancer in California, 1998-2011. JAMA. 2014;312(9):902-14.
7. Acosta JA, Greenlee JA, Gubler KD, Goepfert CJ, Ragland JJ. Surgical margins after needle-localization breast biopsy. Am J Surg. 1995;170(6):643-5; discussion 5-6.
8. Ananthakrishnan P, Balci FL, Crowe JP. Optimizing surgical margins in breast conservation. Int J Surg Oncol. 2012;2012:585670.
9. Lovrics PJ, Cornacchi SD, Farrokhyar F, Garnett A, Chen V, et al. The relationship between surgical factors and margin status after breast-conservation surgery for early stage breast cancer. The American journal of surgery. 2009;197(6):740-6.
10. Biganzoli L, Marotti L, Hart CD, Cataliotti L, Cutuli B, et al. Quality indicators in breast cancer care: An update from the EUSOMA working group. Eur J Cancer. 2017;86:59-81.
11. Maloney BW, McClatchy DM, Pogue BW, Paulsen KD, Wells WA, et al. Review of methods for intraoperative margin detection for breast conserving surgery. J Biomed Opt. 2018;23(10): 1-19.
12.Gray RJ, Pockaj BA, Garvey E, Blair S. Intraoperative margin management in breast-conserving surgery: a systematic review of the literature. Annals of surgical oncology. 2018;25(1):18-27.
13. Goldhirsch A, Winer EP, Coates AS, Gelber RD, Piccart-Gebhart M, et al. Personalizing the treatment of women with early breast cancer: highlights of the St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2013. Ann Oncol. 2013;24(9): 2206-23.
14. Gabriel NH, James LC, Carl JD, Stephen BE, Elizabeth AM, et al. Breast. In: Mahul BA, editor. American Joint Committee on Cancer (AJCC). AJCC cancer staging manual 8th ed New York, NY: Springer. 2017:589–628.
15. Kapoor NS, Eaton A, King TA, Patil S, Stempel M, et al. Should breast density influence patient selection for breast-conserving surgery? Annals of Surgical Oncology. 2013;20(2):600-6.
16. Torabi R, Hsu CH, Patel PN, Dave H, Bouton ME, et al. Predictors of margin status after breast-conserving operations in an underscreened population. Langenbecks Arch Surg. 2013; 398(3):455-62.
17. Lai HW, Huang RH, Wu YT, Chen CJ, Chen ST, et al. Clinicopathologic factors related to surgical margin involvement, reoperation, and residual cancer in primary operable breast cancer - An analysis of 2050 patients. Eur J Surg Oncol. 2018;44(11):1725-35.
18. El-Bastawissi AY, White E, Mandelson MT, Taplin S. Variation in mammographic breast density by race. Ann Epidemiol. 2001;11(4): 257-63.
19. Funk A, Heil J, Harcos A, Gomez C, Stieber A, et al. Efficacy of intraoperative specimen radiography as margin assessment tool in breast conserving surgery. Breast Cancer Res Treat. 2020;179(2):425-33.