The role of the breast radiologist in assisting the breast surgeon on the day of surgery has traditionally been limited to placing a wire or wire-free localization device for women undergoing breast conservation surgery. This has often been perceived as the end of the radiology team's involvement, with the pathologist taking over to inform the surgeon about the accuracy of the excision. However, this view overlooks the crucial role that imaging plays in facilitating the intricate coordination between the surgeon and radiologist before the pathologist's involvement.
Challenges with traditional specimen orientation methods
Breast surgeons employ several different methods for specimen orientation to communicate the specimen orientation to the pathologist for margin assessment during breast conservation surgery.
One of these methods includes dyes or inks applied to the specimen edge. However, this presents a limitation for radiologists, who cannot discern the dyes or inks on a radiograph and thus cannot effectively communicate with the surgeon to minimize the amount of tissue removed from the lumpectomy bed. Another method involving using surgical clips in varying numbers to mark the specimen can result in errors if the clips overlap on the radiograph.
Similarly, using surgical sutures of different lengths to indicate margin locations also has limitations. For instance, the pathologist can infer the medial and inferior margins of the specimen using two strings—one short to indicate the superior margin and one long to indicate the lateral margin. But if the radiograph cuts off the long string, making both strings appear the same length (Fig 1), what is the radiologist left to interpret? How can the radiologist effectively discuss with the surgeon in real-time, while in the operating room, whether additional tissue needs to be removed from the patient?
Better outcomes when all clearly understand specimen orientation
The extent of tissue removal during breast conservation surgery should begin with the radiologist assisting the surgeon. When the surgeon uses an orientation marker that is easily understood by the radiologist, surgeon, and pathologist, it leads to shorter operating room times and less time under general anesthesia.
This also results in better patient outcomes, as the radiologist can discuss margin closeness or clearance of the orientation markers with the surgeon in real time, often reducing the re-excision rate. All of this occurs before the pathologist receives the specimen.
Introducing a new method for communicating specimen margins
We recently implemented MarginMap® specimen orientation charms as a standardized method for marking specimen margins and communicating orientation.
Launched in 2003 by Beekley Medical, the MarginMap® specimen orientation charms system was invented by a surgery and radiology team at Bristol Hospital. It is an effective and accurate method for helping the radiologist quickly and easily communicate the specimen’s margins to the surgeon.
MarginMap® consists of six distinctly shaped radiopaque charms that identify their corresponding margin at a glance (Fig 2). These charms help clarify specimen orientation, reducing miscommunication among the surgical, radiology, and pathology teams. The charms are clearly visible on the radiograph.
We have found that only four of the six charms need to be placed to ensure accuracy at our facility. More importantly, the charms play a crucial role in reducing the re-excision rate for a large majority of patients (Fig 3).
Implementing MarginMap® specimen orientation charms at our hospital
In a recent conversation, Dr. Jennifer Foster, lead surgeon of Surgical Associates, and Dr. Nathanial Kieler, lead pathologist at Bellin Hospital, shared their thoughts about the recent implementation of the MarginMap specimen orientation charms at Bellin Hospital.
Dr. Parris: Was the transition to using the MarginMap specimen orientation charms a difficult process?
Dr. Foster: I found it super straightforward. One of the quickest learning points was to personally move the specimen to the Mayo stand without changing orientation and stitch the MarginMap charms on there.
Dr. Parris: Did your time in the operating room increase having to place the MarginMap charms onto the specimen?
Dr. Foster: It takes me 60 seconds to stitch on. This is negligible.
Dr. Parris: Have you seen a decrease in your re-excision rate?
Dr. Foster: I think slightly. But I would have to look at the actual data.
Dr. Parris: Have the charms affected tissue analysis?
Dr. Foster: Defer to pathology
Dr. Kieler: Jenn, our PA who grosses most of the specimens, admitted that she was slightly annoyed when the change happened just because it was different. But she has adjusted quickly and really likes the MarginMap charms now. It makes it easier for her to orient the specimen. The orientation seems more accurate now.
Dr. Parris: Do you see a better correlation between the pathologist, radiologist, and yourself?
Dr. Foster: Absolutely. Also, when the radiologist is busy, I can better evaluate the specimen mammography myself.
Dr. Kieler: We do think that the correlation is better now.
Dr. Parris: Any other challenges or difficulties faced?
Dr. Foster: Not really. Initially, I got feedback about the product cost, but that dropped quickly.
Dr. Kieler: The transition wasn’t really difficult. It was just a new thing to adjust to.
Dr. Parris: Would you switch to this product if you had to do it all over again?
Dr. Foster: Yes. It gives patients' families great reassurance that we are doing everything to avoid positive margins at the time of surgery.
Improved communication, reduced risk of interpretation errors, better patient care
Our team discovered that implementing a standardized methodology for orienting lumpectomy specimens using MarginMap was challenging at first but proved beneficial. This new orientation system improved communication between departments, reduced the risk of errors in reading the specimens, and decreased the re-excision rate, ultimately leading to improved patient care.
Tchaiko Paris, MDPhD
Breast Section Lead, Diagnostic and Interventional Breast Radiologist, Radiology Chartered - Bellin Health, Green Bay, WI
