SPECIMEN SONOGRAM - Procedure Intra-operative ultrasound for tumor margin assessment as a guide for optimal breast conservation surgery Rashmi Bawa MD,Kap Jae Sung MD Department of Surgery New York Hospital of Queens, Flushing, NY ABSTRACT SPECIMEN SONOGRAM - Procedure INTRODUCTION: The incidence of tumor positive margins in the excisional specimen remains high in breast conserving surgery. The use of imaging modalities in preventing re-resections is increasing and new techniques are evolving. METHODS: In this study, we attempt to use the sonogram to detect the tumor positive margins in breast conserving surgery for breast cancer. We describe the technique of post-excisional specimen sonogram to identify the tumor positive or inadequate margins. RESULTS: 93 patients were recruited in this study. Specimen sonogram detected positive margins and avoided re-excision in 14 patients. Only 12 patients required re-excision because of tumor positive margin on histopathological examination and 5 of them were for DCIS. CONCLUSION: Intraoperative breast specimen sonography is feasible and useful to achieve adequate tumor-free margins in breast conserving surgery for breast cancer. In our study, intraoperative sonography avoided re-excision in 15.5% patients and had reexcision rate of 13.3% 93 Total 34 Sono-positive (37.7%) 20 Inappropriately excised (22.22%) 14 Appropriately excised (15.55%) 56 Sono-negative (62.2%) 12 Re-excision Required (13.3%) 44 No excision required (48.92%) 3 Excluded SPECIMEN SONOGRAPHY 36x48 INTRODUCTION Breast conserving therapy (BCT) has become an important component in the management of breast cancer. Inadequate surgical margins represent a high risk factor leading to adverse clinical outcome in BCT for early-stage breast cancer. The majority of studies report positive resection margins in 20% to 40% of the patients who undergo BCT. This may result in an increased local recurrence (LR) rate or additional surgery and, consequently, having adverse affects on cosmesis, psychological distress, and health care costs. The role of intra-operative ultrasound in BCT has been studied in a few clinical trials and has proven to be useful in identifying and localizing small non-palpable tumors and aids in subsequent excision. The use of ultrasound in identifying tumor positive margins in the tumor resection bed, intraoperatively after breast conserving surgery, has been described in the literature. In this article we present the results of a preliminary study designed to identify the role of excisional specimen sonogram in minimizing inadequate or tumor positive margins. Superior Margin Inferior Margin Medial Margin Lateral Margin METHODS RESULTS After review of the literature a prospective study was designed to examine the use of immediate post-excisional breast specimen sonogram in identifying the tumor positive margins in BCT for malignant breast disease. After IRB approval the study was initiated in April 2008   One surgeon who was trained and certified in breast ultrasound and image guided biopsy participated and performed all the procedures. Only the patients with a sonographically visualized breast mass or palpable mass and confirmed breast cancer by pre-operative core biopsy were included in this study. All patients underwent pre-operative sonoguided identification and needle localization in the operating room by the operating surgeon and resident , prior to wide local excision. A wide local excision was performed with the guidance of localizing needle. The excised breast specimen was oriented by application of different dyes to all six surfaces (Anterior (Superficial), Posterior (Deep), Superior, Inferior, Medial and Lateral) according to the universal color code. The oriented excised specimen was re-examined with sonogram (Sonosite M-Turbo with 13 – 6MHz transducer) by the operating surgeon for the adequacy of margins. Each surface was examined with ultrasound and margins were measured from the tumor border to the specimen surface. Re-excision was performed immediately if any of the margins were found to be inadequate (<2mm). The thickness of re-excised tissue was about 5 mm which does not compromise cosmetic appearance of breast .The excised and re-excised specimens are sent for histopathological examination separately after appropriate labeling. Data collected includes Patient variables, Disease variables, Pre-operative radiological findings, Intra-operative sonogram findings including the specimen sonogram margins, and final histopathological findings including the pathological margins. Careful analysis of the data was performed with a major focus on comparing the difference between histological margins to that of sonographic margins. 93 patients were included in the study. 3 patients were excluded from the study due to labeling error. Of the 90 patients included in the study 34 patients (37.7 %) required intra-operative re-excision based on specimen sonography, 14 patients had appropriate re-excision confirmed by pathological exam and 20 patients had unnecessary re-excision. Of those who did not undergo intra-operative re-excision, only 12 patients (13.3%) were missed by specimen sonography requiring operative re-excision. 5 of those patients had positive margins because of an extra focus of DCIS apart from the invasive cancer and 7 patients had positive invasive cancer at the margin. CONCLUSIONS Intraoperative breast specimen sonogram is feasible and appears to be very useful to achieve adequate tumor free margins in breast conserving surgery leading to decreased re-excision rates. The importance of larger randomized clinical trials comparing this technique to the standard techniques, can not be under stated.