Abstract
Breast-conserving therapy (breast-conserving surgery (BCS) and radiation therapy) is an effective treatment for early-stage breast cancer (BC). Whilst there is consensus that risk of local recurrence (LR) following BCS is increased if the surgical margins are positive (‘ink on tumour’), consensus on what constitutes adequate negative margins has been elusive despite studies spanning decades. Recent SSO–ASTRO guidelines have recommended ‘no ink on tumour’ as the standard for negative margins in BCS for invasive BC. These were underpinned by study-level meta-analysis reporting that a minimally defined negative margin width be adopted for BCS in invasive BC and showing that wider (than a minimum >1 mm) negative margins do not significantly reduce LR risk. Recommendations on a minimum margin width for ductal carcinoma in situ (DCIS) vary substantially from >1 to 10 mm or wider; evidence-based guidelines are being developed and are expected to address ‘how much is enough’ for margin width in DCIS.
Similar content being viewed by others
References
Papers of particular interest, published recently, have been highlighted as • Of importance
Veronesi U, Cascinelli N, Mariani L, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med. 2002;347(16):1227–32.
Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 2002;347(16):1233–41.
Poggi MM, Danforth DN, Sciuto LC, et al. Eighteen-year results in the treatment of early breast carcinoma with mastectomy versus breast conservation therapy: the National Cancer Institute Randomized Trial. Cancer. 2003;98(4):697–702.
Clarke M, Collins R, Darby S, et al. Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet. 2005;366(9503):2087–106.
Virnig BA, Tuttle TM, Shamliyan T, Kane RL. Ductal carcinoma in situ of the breast: a systematic review of incidence, treatment, and outcomes. J Natl Cancer Inst. 2010;102(3):170–8.
Early Breast Cancer Trialists’ Collaborative Group, Correa C, McGale P, et al. Overview of the randomized trials of radiotherapy in ductal carcinoma in situ of the breast. J Natl Cancer Inst Monogr. 2010;2010(41):162–77.
Virnig BA, Shamliyan T, Tuttle TM, Kane RL, Wilt TJ. Diagnosis and management of ductal carcinoma in situ (DCIS). Evidence Report Number 185, prepared by the Minnesota Evidence-based Practice Centre for the Agency for Healthcare Quality and Research (AHQR); Publication No. 09-E018. Rockville, MD. AHQR, September 2009.
Newman LA, Kuerer HM. Advances in breast conservation therapy. J Clin Oncol. 2005;23(8):1685–97.
Morrow M, Strom EA, Bassett LW, et al. Standard for breast conservation therapy in the management of invasive breast carcinoma. CA: Cancer J Clin. 2002;52(5):277–300.
Houssami N, Macaskill P, Marinovich ML, et al. Meta-analysis of the impact of surgical margins on local recurrence in women with early-stage invasive breast cancer treated with breast-conserving therapy. Eur J Cancer. 2010;46(18):3219–32.
Singletary SE. Surgical margins in patients with early-stage breast cancer treated with breast conservation therapy. Am J Surg. 2002;184(5):383–93.
Houssami N, Macaskill P, Marinovich ML, Morrow M. The association of surgical margins and local recurrence in women with early-stage invasive breast cancer treated with breast-conserving therapy: a meta-analysis. Ann Surg Oncol. 2014;21(3):717–30. Evidence review and meta-analysis that contributed to the development of SSO-ASTRO guidelines on margins in invasive breast cancer.
Carlson RW, Allred DC, Anderson BO, et al. Breast cancer. Clinical practice guidelines in oncology. J Natl Compr Cancer Netw. 2009;7(2):122–92.
Schwartz GF, Veronesi U, Clough KB, et al. Consensus conference on breast conservation. J Am Coll Surg. 2006;203(2):198–207.
Shamliyan T, Wang SY, Virnig BA, Tuttle TM, Kane RL. Association between patient and tumor characteristics with clinical outcomes in women with ductal carcinoma in situ. J Natl Cancer Inst Monogr. 2010;2010(41):121–9.
Wang SY, Chu H, Shamliyan T, et al. Network meta-analysis of margin threshold for women with ductal carcinoma in situ. J Natl Cancer Inst. 2012;104(7):507–16. Meta-analysis providing comprehensive analysis of data on margins in DCIS.
Morrow M, Harris JR, Schnitt SJ. Surgical margins in lumpectomy for breast cancer—bigger is not better. N Engl J Med. 2012;367(1):79–82.
Moran MS, Schnitt SJ, Giuliano AE, et al. Society of Surgical Oncology-American Society for Radiation Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in stages I and II invasive breast cancer. J Clin Oncol. 2014;32(14):1507–15. SSO–ASTRO clinical guidelines with recommendations on margins in invasive breast cancer.
Morrow M. Margins in breast-conserving therapy: have we lost sight of the big picture? Expert Rev Anticancer Ther. 2008;8(8):1193–6.
Taghian A, Mohiuddin M, Jagsi R, Goldberg S, Ceilley E, Powell S. Current perceptions regarding surgical margin status after breast-conserving therapy: results of a survey. Ann Surg. 2005;241(4):629–39.
Luini A, Rososchansky J, Gatti G, et al. The surgical margin status after breast-conserving surgery: discussion of an open issue. Breast Cancer Res Treat. 2009;113(2):397–402.
MacDonald S, Taghian AG. Prognostic factors for local control after breast conservation: does margin status still matter? J Clin Oncol. 2009;27(30):4929–30.
McCahill LE, Single RM, Aiello Bowles EJ, et al. Variability in reexcision following breast conservation surgery. J Am Med Assoc. 2012;307(5):467–75.
Sakamoto G, Inaji H, Akiyama F, Haga S, Hiraoka M, Inai K et al. General rules for clinical and pathological recording of breast cancer 2005. Breast Cancer. 2005;12(Suppl-27)
Dixon JM, Houssami N. Bigger margins are not better in breast conserving surgery. BMJ. 2012;345, e5855.
Morrow M, Jagsi R, Alderman AK, et al. Surgeon recommendations and receipt of mastectomy for treatment of breast cancer. J Am Med Assoc. 2009;302(14):1551–6.
Parvez E, Hodgson N, Cornacchi SD, et al. Survey of American and Canadian general surgeons’ perceptions of margin status and practice patterns for breast conserving surgery. Breast J. 2014;20(5):481–8.
Moran MS, Schnitt SJ, Giuliano AE, et al. Society of Surgical Oncology-American Society for Radiation Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in stages I and II invasive breast cancer. Ann Surg Oncol. 2014;21(3):704–16. SSO-ASTRO clinical guidelines with recommendations on margins in invasive breast cancer.
Moran MS, Schnitt SJ, Giuliano AE, et al. Society of Surgical Oncology-American Society for Radiation Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in stages I and II invasive breast cancer. Int J Rad Oncol Biol Phys. 2014;88(3):553–64. SSO-ASTRO clinical guidelines with recommendations on margins in invasive breast cancer.
Dixon JM, Thomas J. In regard to Moran et al. Int J Rad Oncol Biol Phys. 2014;89(5):1139.
Early AP. SSO-ASTRO consensus guidelines for breast-conserving surgery with whole-breast radiation: in regard to Moran et al. Int J Radiat Oncol Biol Phys. 2014;89(5):1138–9.
Hunt KK, Smith BD, Mittendorf EA. The controversy regarding margin width in breast cancer: enough is enough. Ann Surg Oncol. 2014;21(3):701–3.
Buchholz TA, Somerfield MR, Griggs JJ, et al. Margins for breast-conserving surgery with whole-breast irradiation in stage I and II invasive breast cancer: American Society of Clinical Oncology endorsement of the Society of Surgical Oncology/American Society for Radiation Oncology consensus guideline. J Clin Oncol. 2014;32(14):1502–6.
Moran MS, Houssami N, Schnitt SJ, Morrow M. In reply to Dixon and Thomas. Int J Radiat Oncol Biol Phys. 2014;89(5):1139–41.
Harness JK, Giuliano AE, Pockaj BA, Downs-Kelly E. Margins: a status report from the annual meeting of the American Society of Breast Surgeons. Ann Surg Oncol. 2014;21(10):3192–7.
Greenup RA, Peppercorn J, Worni M, Hwang ES. Cost implications of the SSO-ASTRO consensus guideline on margins for breast-conserving surgery with whole breast irradiation in stage I and II invasive breast cancer. Ann Surg Oncol. 2014;21(5):1512–4.
Schnitt SJ, Moran MS, Houssami N, Morrow M. The Society of Surgical Oncology-American Society for Radiation Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in stages I and II invasive breast cancer: perspectives for pathologists. Arch Pathol Lab Med. 2015;139(5):575–7.
Pilewskie M, Ho A, Orell E, et al. Effect of margin width on local recurrence in triple-negative breast cancer patients treated with breast-conserving therapy. Ann Surg Oncol. 2014;21(4):1209–14.
Bernardi S, Bertozzi S, Londero AP, Gentile G, Angione V, Petri R. Influence of surgical margins on the outcome of breast cancer patients: a retrospective analysis. World J Surg. 2014;38(9):2279–87.
Behm EC, Beckmann KR, Dahlstrom JE, et al. Surgical margins and risk of locoregional recurrence in invasive breast cancer: an analysis of 10-year data from the Breast Cancer Treatment Quality Assurance Project. Breast. 2013;22(5):839–44.
Bodilsen A, Bjerre K, Offersen BV, Vahl P, Mele M, Dixon MJ et al. Importance of margin width and re-excision in breast conserving treatment of early breast cancer; a Danish breast cancer cooperative group study of 11,900 women. Abstract presented at the San Antonio Breast Cancer Symposium (SABCS) 2015; accessed December 2015 (www.abstracts2view.com/sabcs15)
Pilewskie M, Morrow M. Extent and role of margin control for DCIS managed by breast-conserving surgery. In: Newman LA, Bensenhaver JM, editors. Ductal carcinoma in situ and microinvasive/borderline breast cancer. New York: Springer; 2015. p. 67–83.
National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology, Breast Cancer Version 1.2016. http://www.nccn.org. 2015. National Comprehensive Cancer Network. 12-14-2015.
National Institute for Health and Care Excellence (NICE). Early and locally advanced breast cancer: diagnosis and treatment: NICE guidelines [CG80]. https://www.nice.org.uk/guidance/cg80/chapter/guidance#surgery-to-the-breast. 2009. National Institute for Health and Care Excellence. 12-14-2015.
Vicini FA, Recht A. Age at diagnosis and outcome for women with ductal carcinoma-in-situ of the breast: a critical review of the literature. J Clin Oncol. 2002;20:2736–44.
Kong I, Narod SA, Taylor C, et al. Age at diagnosis predicts local recurrence in women treated with breast-conserving surgery and postoperative radiation therapy for ductal carcinoma in situ: a population-based outcomes analysis. Curr Oncol. 2014;21:e96–104.
Correa C, McGale P, Taylor C, et al. Overview of the randomized trials of radiotherapy in ductal carcinoma in situ of the breast. J Natl Cancer Inst Monogr. 2010;2010(41):162–77.
Rudloff U, Jacks LM, Goldberg JI, et al. Nomogram for predicting the risk of local recurrence after breast-conserving surgery for ductal carcinoma in situ. J Clin Oncol. 2010;28(23):3762–9.
Vicini F, Beitsch P, Quiet C, et al. Five-year analysis of treatment efficacy and cosmesis by the American Society Of Breast Surgeons Mammosite Breast Brachytherapy Registry Trial in patients treated with accelerated partial breast irradiation. Int J Radiat Oncol Biol Phys. 2011;79:808–17.
Hathout L, Hijal T, Theberge V, et al. Hypofractionated radiation therapy for breast ductal carcinoma in situ. Int J Radiat Oncol Biol Phys. 2013;87:1058–63.
Ben-David MA, Sturtz DE, Griffith KA, et al. Long-term results of conservative surgery and radiotherapy for ductal carcinoma in situ using lung density correction: the University of Michigan experience. Breast J. 2007;13:392–400.
Solin LJ, Fourquet A, Vicini FA, et al. Long-term outcome after breast-conservation treatment with radiation for mammographically detected ductal carcinoma in situ of the breast. Cancer. 2005;103:1137–46.
Rodrigues N, Carter D, Dillon D, Parisot N, Choi DH, Haffty BG. Correlation of clinical and pathologic features with outcome in patients with ductal carcinoma in situ of the breast treated with breast-conserving surgery and radiotherapy. Int J Radiat Oncol Biol Phys. 2002;54:1331–5.
Cutuli B, Cohen-Solal-Le NC, De LB, et al. Ductal carcinoma in situ of the breast results of conservative and radical treatments in 716 patients. Eur J Cancer. 2001;37:2365–72.
Hiramatsu H, Bornstein BA, Recht A, et al. Local recurrence after conservative surgery and radiation therapy for ductal carcinoma in situ: possible importance of family history. Cancer J Sci Am. 1995;1:55–61.
Cataliotti L, Distante V, Ciatto S, et al. Intraductal breast cancer: review of 183 consecutive cases. Eur J Cancer. 1992;28:917–20.
Turaka A, Freedman GM, Li T, et al. Young age is not associated with increased local recurrence for DCIS treated by breast-conserving surgery and radiation. J Surg Oncol. 2009;100:25–31.
Van Zee KJ, Subhedar P, Olcese C, Patil S, Morrow M. Relationship between margin width and recurrence of ductal carcinoma in situ: analysis of 2996 women treated with breast-conserving surgery for 30 years. Ann Surg. 2015;262:623–31. The largest study of margins in DCIS showing that receipt of whole-breast radiation modified the effect of margin width on the risk of local recurrence.
Meattini I, Livi L, Franceschini D, et al. Role of radiotherapy boost in women with ductal carcinoma in situ: a single-center experience in a series of 389 patients. Eur J Surg Oncol. 2013;39:613–8.
Chuwa EWL, Tan VHS, Tan P-H, Yong W-S, Ho G-H, Wong C-Y. Treatment for ductal carcinoma in situ in an Asian population: outcome and prognostic factors. ANZ J Surg. 2008;78:42–8.
MacAusland SG, Hepel JT, Chong FK, et al. An attempt to independently verify the utility of the Van Nuys prognostic index for ductal carcinoma in situ. Cancer. 2007;110:2648–53.
Bijker N, Meijnen P, Peterse JL, et al. Breast-conserving treatment with or without radiotherapy in ductal carcinoma-in-situ: ten-year results of European Organisation For Research And Treatment Of Cancer Randomized Phase III Trial 10853—a study by the EORTC breast cancer cooperative group and EORTC radiotherapy group. J Clin Oncol. 2006;24:3381–7.
Chasle J, Delozier T, Denoux Y, Marnay J, Michels J-J. Immunohistochemical study of cell cycle regulatory proteins in intraductal breast carcinomas—a preliminary study. Eur J Cancer. 2003;39:1363–9.
Nakamura S, Woo C, Silberman H, Streeter J, Lewinsky BS, Silverstein MJ. Breast-conserving therapy for ductal carcinoma in situ: a 20-year experience with excision plus radiation therapy. Am J Surg. 2002;184:403–9.
Neuschatz AC, DiPetrillo T, Safaii H, Lowther D, Landa M, Wazer DE. Margin width as a determinant of local control with and without radiation therapy for ductal carcinoma in situ (DCIS) of the breast. Int J Cancer. 2001;96:97–104.
Fowble B, Hanlon AL, Fein DA, et al. Results of conservative surgery and radiation for mammographically detected ductal carcinoma in situ (DCIS). Int J Radiat Oncol Biol Phys. 1997;38:949–57.
Sweldens C, Peeters S, Van LE, et al. Local relapse after breast-conserving therapy for ductal carcinoma in situ: a European single-center experience and external validation of the memorial Sloan-Kettering cancer center DCIS nomogram. Cancer J. 2014;20:1–7.
Kim H, Noh JM, Choi DH, et al. Excision alone for small size ductal carcinoma in situ of the breast. Breast. 2014;23:586–90.
Hughes LL, Wang M, Page DL, et al. Local excision alone without irradiation for ductal carcinoma in situ of the breast: a trial of the Eastern Cooperative Oncology Group. J Clin Oncol. 2009;27(32):5319–24.
Dunne C, Burke JP, Morrow M, Kell MR. Effect of margin status on local recurrence after breast conservation and radiation therapy for ductal carcinoma in situ. J Clin Oncol. 2009;27:1615–20.
Morrow M, Katz SJ. Margins in ductal carcinoma in situ: is bigger really better? J Natl Cancer Inst. 2012;104(7):494–5.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
Nehmat Houssami receives research support through the National Breast Cancer Foundation (NBCF Australia) Breast Cancer Research Leadership Fellowship.
M. Luke Marinovich receives research support through a Cancer Institute NSW Early Career Fellowship.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Additional information
This article is part of the Topical Collection on Local-Regional Evaluation and Therapy
Rights and permissions
About this article
Cite this article
Houssami, N., Marinovich, M.L. Margins in Breast-Conserving Surgery for Early Breast Cancer: How Much is Good Enough?. Curr Breast Cancer Rep 8, 127–134 (2016). https://doi.org/10.1007/s12609-016-0204-9
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12609-016-0204-9