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Managing Positive Margins After Oncoplastic Surgery: A Case Series
Mohyee Ayouty, MS1, Yurie Sekigami, MD2, Nicholas Kraus, MS1, Sarah Persing, MD, MPH3, Stephen Naber, MD, PhD2, Sayedeh Aleali, MD2, Salvatore Nardello, DO4, Abhishek Chatterjee, MD, MBA2.
1Tufts University School of Medicine, Boston, MA, USA, 2Tufts Medical Center, Boston, MA, USA, 3The Johns Hopkins Hospital, Baltimore, MD, USA, 4Tufts Medical Center Community Care, Boston, MA, USA.

PURPOSE: Oncoplastic breast conservation surgery for breast cancer is increasingly becoming a part of routine surgical management. Oncoplastic surgery involves a partial mastectomy and simultaneously reconstructing the breast using volume displacement or volume replacement techniques. Level 2 volume displacement oncoplastic surgery (LVOS) occurs when 20-50% of the breast is removed as part of the cancer resection followed by a volume displacement reconstructive design using a reduction mammoplasty or mastopexy skin incision pattern. Although uncommon, positive margins in LVOS may be treated with re-excision rather than completion mastectomy. To date, data is scarce describing techniques for re-excision of a positive margin after performing LVOS using reduction mammoplasty. We present two patients who underwent common LVOS techniques who subsequently had positive margins. We describe our techniques for subsequent re-excision of positive margins. METHODS: Two patients presented with positive margins after LVOS for ductal carcinoma in situ (DCIS), with 20-50% of breast tissue removed. The first patient underwent LVOS using a superomedial pedicle with a circumvertical skin incision which removed the lower pole (5-7 o'clock region) of the breast containing the cancer. The patient had a positive superior margin and underwent a subsequent operation for focused re-excision of the superior margin (inferior section of the superomedial pedicle). The second patient underwent LVOS using an inferior pedicle, Wise pattern skin incision for DCIS in the upper inner quadrant. The patient had a positive margin in the medial aspect of the pathological sample and underwent a second operation to excise an additional medial shave margin. Communication between surgery and pathology during the first LVOS in both case examples allowed the positive margin to be reliably identified and mapped to the region of the breast from which the margin arose. In the operating room, suture release and gentle spreading allow for the restoration of the original partial mastectomy defect. Clips marking the original partial mastectomy region are identified at the positive margin border, followed by a shave and placement of new clips at the new margin. The original tissue rearrangement is then re-approximated. RESULTS: Re-excision of the positive margins was performed within three weeks of the initial operation. Both subsequent operations for our two patients achieved negative margins in the re-excised tissue samples without requiring completion mastectomy. Both patients received adjuvant radiation and subsequent adjuvant hormonal therapy after radiation and were very satisfied with their oncologic and reconstructive outcomes. Our results demonstrate that a positive margin in LVOS does not mandate a completion mastectomy and can obtain negative margins in the appropriately selected patients (Figure 1). CONCLUSION: We present two patients who underwent margin re-excision surgery after positive margins following two different LVOS techniques. The re-excision of additional tissue via focused shaved margins in subsequent operations was possible due to communication between the surgical and pathology team members. This allowed for the anatomical identification and oncologically accurate removal of additional breast tissue.


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