Use of Confocal Microscopy to Assess the Margins of a Breast Lumpectomy with Invasive Ductal Carcinoma

13th May 2021

PD Dr. Claudia Rauh, MD Senior Breast Surgeon
Prof. Michael Müller, MD Head of gynecology department
Inselspital Frauenklinik, Bern, Switzerland

Technology Review

Confocal microscopy is a recognized imaging method that provides high resolution images of fresh tissue in a timely manner. The Histolog® Scanner integrates this approach in a new medical imaging modality enabling real-time visualization of fresh specimens ranging from biopsies to large surgical excisions. The whole specimen surface is imaged in a few minutes to obtain morphological information up to subcellular details, allowing the visualization of cancerous lesions immediately after sampling or excision.

Case Report

A 61-year-old woman was diagnosed with a bilateral invasive ductal carcinoma NST without in-situ components. Immunophenotype profile was determined and showed a luminal-A-like carcinoma on both sides. Mammography revealed lesions of 4x6x5mmin the left breast centrally and of 16x13x20mmin the right breast in the lower inner quadrant. A primary breast conserving surgical approach was recommend due to tumor type and stage at diagnosis in the multidisciplinary tumor board. In regard to localization and slight indignation of the cutis of the right BC an oncoplastic surgery with a minimal mastopexy was decided upon.

Preoperative stereotactic wire localization of the lesion in the left breast was performed by the surgeon. Surgical specimen of 1x4x3 cm (5 g) was excised using a scalpel and scissors to avoid cauterization of the surface. Following standard-of-care procedure, the orientation of the excised specimen was marked using surgical sutures and clip markers for radiography as physical markers and the lumpectomy was examined by gross inspection by the surgeon. The specimen was then prepared for imaging with the Histolog ® Scanner: tissue was stained with the Histolog ® Dip, a fluorescent agent that enhances the visualization of negatively charged components, such as cell nuclei and some proteins, with the Histolog ® Scanner. Tissue preparation took less than 1 minute. Normal breast structures such as fat, connective tissue and lobules were identified on the Histolog ® images by the surgeon who had followed a brief introduction to the content of breast tissue Histolog ® images before surgery (Fig. 1). The specimen was then sent to the radiology department according to center Standard-of-Care for an intraoperatively radiogram aiming at confirming the wire, initial clip marking and lesion localizations.

Fig. 1

During the gross inspection, Dr. Rauh had noticed the wire-markers were very close to the lateral margin, which was confirmed by the radiogram. The surgeon decided to perform a secondary excision in the area corresponding to the lateral margin, obtaining a piece of 4x2x3 cm (7 g). The secondary excision was also prepared and imaged with the Histolog Scanner. Invasive ductal carcinoma was identified on the medial surface margin by surgeon who quickly recognized the abnormal structure on the Histolog Scanner images (Fig. 2 and 3). Presence of this cancerous lesion was later confirmed by the final pathology assessment.

Fig 2.

Fig. 3

On the right breast, an oncoplastic resection with resection of the skin has been performed. The excised specimen was imaged with Histolog ® Scanner and margins were assessed as non-cancerous by surgeon. This assessment was later confirmed by the final pathology analyses following standard-of-care.

Conclusion

Cancerous and healthy tissue were correctly identified by the surgeon on Histolog Scanner images during the surgery, in agreement with the final histopathological assessment. The Histolog Scanner was easily integrated in the clinical workflow and provided relevant images. Surgeons who are usually not used to interpreting morphology content could distinguish cancer cells, with only a short familiarization to Histolog Scanner images. With experience, this solution is expected to quickly provide clinicians with essential and readable information, with the common goal of improving patient care.