Dr. Dennis Holmes has built his career on eliminating the deadly disease of breast cancer, while still preserving and managing breast tissue in a way that achieves the best possible cosmetic outcome. Known as oncoplasty, this field has always been challenged by the need to obtain a clear margin of healthy tissue around any cancerous tumor or lump that is to be removed by surgery and yet still maintain enough tissue to make any necessary breast reconstruction feasible.
“In breast oncology, we’ve always been limited in our ability to assess surgical margins intraoperatively,” explained Dr. Holmes. “Compared to other tissues, breast tissue is very fatty and does not process well in a lab to provide instant results. It’s better to ‘fix’ it overnight and then process it, but that does not give us the data we need in the operating room (OR). We can call a pathologist to the OR to assist us with margin analysis, but they can usually only provide a very limited assessment. It probably amounts to about 1% of the total margin surface analysis that is needed. This leaves 99% of the margin unevaluated.”
MarginProbe changes the equation
Dr. Holmes cited a highly-effective tool, MarginProbe, that does answer the challenge of interoperative margin assessments to provide assurance of proper margins during surgery while preserving breast tissue as much as possible. The surgeon participated in the original clinical trials that demonstrated MarginProbe’s ability to address positive margins (detection of cancer) on a specimen that was 220% higher than the normal standard of care. Based on such stellar performance, he has been using the technology since these initial results in 2010.
“MarginProbe enables us to look at the entire surface of the margin while we’re still in surgery,” said Dr. Holmes. “If you have a situation where margin assessment is critical, this approach gives me more confidence in my ability to complete the operation successfully.”
“This is also important as breast surgeries move increasingly to outpatient surgery centers, instead of a major hospital where a pathologist is available,” he continued. “MarginProbe enables confidence in a margin assessment even without a pathologist. That liberates the breast surgeon to operate in a variety of facilities.”
MarginProbe’s impact on oncoplasty
Due to the sensitivity of MarginProbe in detecting cancerous tissue, there has been some discussion about whether using the probe will cause the removal of more tissue than is necessary. Dr. Holmes cited recent research that proved that the opposite is true. The use of MarginProbe enables what is known as directed cavity shavings, as opposed to full-cavity shavings, due to the higher level of confidence in margins provided by the device.
“Surgeons may think they are taking more tissue, but they’re actually taking less,” the physician explained. “The reason is that surgeons typically take shave margins to be safe. This includes not only the specimen, but six additional margins. The problem is that these margins could actually be clear tissue. MarginProbe makes this unnecessary. With Marginprobe, we look at the entire surface of the tumor, if it is only close to the medial lateral margin, then that’s all we take. By taking only directed margins, less tissue is taken overall.”
But tissue removed during the first surgery is not the only issue in ensuring a successful oncoplastic procedure. If correct margins are not removed the first time, an additional surgery known as re-excision may be required. This additional surgery can significantly drive up the negative impact to cosmetic outcomes.
“The most important challenge with oncoplasty is that we mobilize tissue and move it to different parts of the breast to improve appearance,” stated Dr. Holmes. “Because of this, it may be difficult to clearly identify the same margin if re-excision is needed later. If the margin cannot be located, a full mastectomy may be required. This makes it all the more critical to be confident in your margins the first time so you don’t need to go back in.”
Dr. Holmes shared that his level of confidence comes from multiple studies that show MarginProbe reduces the reexcision rate by 50% or more. A recent study shows reexcision rate falling by as much as 79%.
Spreading the benefits of oncoplasty
Dr. Holmes is co-director of the oncoplastic course at the American Society of Breast Surgeons (ASBS) this year and enrollment for the course is the highest ever. The surgeon feels this trend is increasing, and that there is a high level of interest in performing oncoplastic procedures among breast surgeons.
“Oncoplasty was much more of a niche operation 5 years ago, but it has become a major initiative with ASBS as of this year,” said Dr. Holmes. “There are two main categories of procedures: Level 1 where oncoplastic procedures can be applied to even a simple lumpectomy when closing the wound to improve cosmetics. And level 2 where larger breast remodeling operations are performed to improve symmetry. Currently only 5-10% of surgeons can perform a level 2 operation, but the goal is to push 80% of breast surgeons to level 1 over the next 5 years and then migrate these surgeons to level 2. The ASBS goal is to establish regional courses across the country to build this effort out. With this initiative to make oncoplastic surgery an option to all patients, devices like MarginProbe become even more essential.”
Dennis R. Holmes, M.D., F.A.C.S.
- Specialist in minimally-invasive breast surgery, including oncoplastic surgery, hidden-scar nipple-sparing mastectomy, intraoperative radiotherapy, cryoablation (cancer tumor freezing), and lymph node-sparing surgery
- Currently serving as Interim Director of the Margie Petersen Breast Center at St. John’s Health Center
- Former Chief Breast Surgeon and Medical Director of the Los Angeles Center for Women’s Health
- Former Chief Breast Cancer Surgeon, and Breast Cancer Research Committee Co-Chair at the University of Southern California (U.S.C.) Kenneth Norris Comprehensive Cancer Center
- Member of the education committee of the American Society of Breast Surgeons who recently led the development of national surgical practice guidelines for the use of preoperative chemotherapy prior to breast cancer surgery
- Fellow of the American College of Surgeons
- Recently selected as Board Chair and President of the TARGIT Collaborative Group, a national research and education organization
- National Principal Investigator of the FROST Trial, a clinical trial evaluating the use of cryoablation instead of surgery for the treatment of early stage breast cancer
- Strong advocate for individualized cancer therapy, in which care is adapted to the severity of the cancer to avoiding unnecessary side effects
- 2003 graduate of the U.S.C. Breast Surgery Fellowship Training Program, one of most innovative and progressive breast surgery training programs in the country
Disclaimer: The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of Dune Medical.