Reexcisions in Breast-Conserving Surgery for Breast Cancer: Can They Be Avoided?
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- Theodore, L. Ann Surg Oncol (2008) 15: 945. doi:10.1245/s10434-007-9688-x
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In a recent issue of the Journal, O’Sullivan and colleagues1 report on their efforts for microscopic disease-free margins even when multiple reexcisions in breast conservation therapy for early-stage breast cancer are required. On one hand, positive or close margins after breast-conserving surgery (BCS) have been recognized as an important risk factor of local recurrence2,3 and reduced overall survival.4 On the other hand, improved adjuvant radiotherapy including boost5 and systemic adjuvant chemotherapy, endocrine therapy for estrogen receptor–positive tumors, and probably targeted therapy for HER2-positive breast cancer reduces distant recurrence risk and may also decrease the rate of local recurrence after BCS. Reexcisions may result in poor cosmetic results and poor psychosocial status of the patients. Thus, two crucial questions with major clinical consequences arise: given the efficacy of modern adjuvant treatment, could we avoid reexcisions? And if not, should we consider total mastectomy with new plastic reconstruction techniques that offer good cosmetic results with acceptable morbidity?5
A complete surgical resection (R0) of the primary tumor still remains the standard treatment for localized solid tumors despite the availability of effective adjuvant chemoradiotherapy. A meta-analysis of randomized trials4 and a review of the role of local control in overall survival of patients with breast cancer considering the biologic processes underlying local and distant metastases6,7 reveal that local control affects overall survival. Presently, we cannot underestimate the effect of local control on survival—not only for breast cancer,3,4,7 but also for various cancer types, including early-stage gastric tumors.8–10 Better survival rates can be achieved with adequate extensive surgery11–15 or limited surgery plus chemoradiation.16,17
Another important risk factor for local recurrence, beyond margin status, is young age.2,4,18 The cause of increased local recurrence risk for some of these young patients with breast cancer is that they may be carriers of mutations in BRCA1 or BRCA2 genes.19 These patients, as a result of BRCA-deficient cells, have an increased risk of disease recurrence in residual breast tissue and can benefit from a bilateral mastectomy instead of BCS.19–21 The high risk of breast cancer due to BRCA-deficient cells has been well documented in women with BRCA mutations, and risk-reducing prophylactic surgery is suggested.22–24
Local control continues to be an important goal in the treatment of localized breast cancer despite the availability of current chemoradiotherapy and targeted therapy. Resection margins free of tumor cells still remains a standard of care. Whether this goal in clinical practice will be realized with BCS and reexcisions or with total mastectomy and plastic reconstructions is a matter of discussion with each individual patient. For patients younger than 40 years old, genetic testing, especially if there is a family history of breast cancer, and specific, more extensive surgery should be considered for BRCA mutation carriers.