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\begin{document}

\title{Intraoperative margin assessment of large breast specimens}



\author[1]{Bothaina Nakad}%
\author[2]{Paula Simovici}%
\author[1]{Daria Milevsky}%
\author[1]{Asia Brodsky}%
\affil[1]{Bnai Zion Medical Center}%
\affil[2]{Bnai Zion Hospital}%


\vspace{-1em}



  
  \date{May 24, 2024}


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\begin{abstract}
We present here a case of the utility of Tomosynthesis in real time
during surgery for margin assessment. This vigorous planning of
operative steps allows one-step procedure with maximal outcome.%
\end{abstract}%



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\textbf{Case report -- Intraoperative margin assessment of large breast
specimens}

B. Nakad, P.Simovici, D.Milevsky, A. Brodsky

Bothaina Nakad -- Email: bthnnakad@gmail.com ORCID ID
https://orcid.org/0000-0003-3224-8839 Surgery Department, Bnai-Zion
Medical Center, Haifa, Israel Paula Simovici -- Email:
Paula.Simovitz@b-zion.org.il Radiology Department, Bnai-Zion Medical
Center, Haifa, Israel Daria Milevsky -- Email: danielmilevsky@yahoo.com
Surgery Department, Bnai-Zion Medical Center, Haifa, Israel Asia Brodsky
-- Email: asiabrodsky@gmail.com Surgery Department, Bnai-Zion Medical
Center, Haifa, Israel

\textbf{Abstract} We present here a case of the utility of Tomosynthesis
in real time during surgery for margin assessment. This vigorous
planning of operative steps allows one-step procedure with maximal
outcome.

\textbf{Introduction} The current intraoperative margin evaluation
methods used routinely are not adequate. Frozen sections of all
suspected margins are not feasible specifically in a big specimen due to
longer operating time and more difficult association with the correct
orientation of the margins (1). The use of Margin probe has not been
proven to have a clinical significance and increases the False-Positive
rates of positive margins (2).

\textbf{Methods} A 40 years old patient, with Infiltrative Ductal
Carcinoma, ERP PRN HER2P KI67 9\% and cN1, with a complete clinical
response post Neoadjuvant Herceptin-Perjeta, was planned for a left
Mastectomy with oncoplastic reconstruction. A revision of all pre-NAC
and post-NAC imaging, including a breast MRI and Tomosynthesis, revealed
multiple areas in the breast with calcifications, in proximity to the
skin. The proximity and distance of these foci of calcifications were
measured, and for those less than 1 cm from the skin, a total of four
foci, we used a skin-mark localization. Accordingly, the oncoplastic
stages of the operation were planned with planned incisions in the skin.

Intraoperatively and after resection of the breast, the mastectomy
specimen was evaluated using Tomosynthesis with an orientation system of
margins in accordance with the anatomical orientation of the breast
(Cranial, Medial and Lateral). One additional margin resection was
decided on in real-time by the breast radiologist and breast surgeons,
the medial border due to proximity of calcifications to the actual
margin. There was no need for additional resections in the anterior
margin, including the skin.

\textbf{Results} The final pathology was high-grade DCIS. The only close
margin less then 2 mm was the lower medial margin, which was resected
during surgery after imaging evaluation. This allowed complete resection
of areas marked pre-surgery and confirmed intra-operatively by specimen
Tomosynthesis.

\textbf{Conclusion} The use of real-time Tomosynthesis allowed our
patient to undergo a one-step operation of mastectomy and a tissue
expander with highly satisfactory oncologic and cosmetic outcomes.

\textbf{Legend to Figures}

\textbf{Figure 1} CC and MLO images of the left breast. Note the
extensive calcifications spread through the breast tissue.

\textbf{Figure 2} US image of suspected calcifications with close
proximity, 0.36 cm from the skin. This evaluation allowed pre-surgery
localization of potential involved margins.

\textbf{Figure 3} Final breast specimen, oriented and prepared for
Tomosynthesis scan.







\textbf{Conflict of interest disclosure}

The authors have no conflicts of interest to disclose that are relevant
to this article.

\textbf{Proof of Consent}

I confirm that written patient consent has been signed and collected in
accordance with the journal's~patient consent policy, and that I have
added a patient consent statement asserting this at the bottom of the
manuscript's title page. I will retain the~original written consent
form~and provide it to the Publisher if requested.

\textbf{References}

Valdes EK, Boolbol SK, Cohen JM, Feldman SM. Intra-operative touch
preparation cytology; does it have a role in re-excision lumpectomy? Ann
Surg Oncol. 2007;14:1045--50

LeeVan E, Ho BT, Seto S, Shen J. Use of MarginProbe as an adjunct to
standard operating procedure does not significantly reduce re-excision
rates in breast conserving surgery. Breast Cancer Res Treat. 2020
Aug;183(1):145-151. doi: 10.1007/s10549-020-05773-5. Epub 2020 Jul 1.
PMID: 32607640

\textbf{Author Contribution}

B. Nakad: writing, editing and submitting P.Simovici: reviewing
D.Milevsky: reviewing A. Brodsky: reviewing and editing

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