Current options and future perspectives for margin assessment in breast conservation surgery

Cancer free margins from breast conservation surgery (BCS) are essential to avoid re-excision procedures, minimize risk of local recurrence, and for adjuvant therapy without delay. Approximately 20-25 % of patients who undergo BCS require additional procedures to remove residual disease, suggesting an ongoing need for effective intraoperative margin assessment. Intraoperative pathology assessment by frozen sections and cytology yields high diagnostic accuracy, but is time-consuming, resource-intensive, and evaluates limited sampling points. Alternative technologies provide more rapid results but are limited by relatively low sensitivity. Technologies in development show promise for diagnostic accuracy but remain to be proven in clinical practice. The objective of this study is to provide a comprehensive summary of current margin assessment methods for surgeons to utilize in the intraoperative setting.

This study reviewed scientific literature from January 2009 to December 2022 consisting of 40 manuscripts of current and proposed intraoperative margin assessment techniques for BCS from PubMed and Google Scholar. Overall, eight current technologies and ten technologies under development were evaluated based on the type of technology employed.

Pathologic evaluation with cytology had the highest sensitivity and specificity with 97 % and 99 % respectively. Technologies utilizing bioimpedance spectroscopy had sensitivities ranging from 13 % to 87 %. Mass spectrometry devices had sensitivities ranging from 80 % to 100 % and specificities ranging from 84 % to 98.85 %. Other technologies including optical coherence tomography, pharmacology, and X-ray combined technologies had sensitivities of 93 %-96 %, 49.3 %-98 %, and 56 %-85.6 % respectively.

The effectiveness in lowering re-excision rates derived from their respective advantages, limitations, sensitivity, and specificity were reviewed and have yet to replace pathologic assessment. Appropriate and effective intraoperative margin assessment would lower final positive margins and subsequent re-excision rates in BCS. Surgeons should utilize technology based on availability and experience.