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New Guidelines on the Adequacy of Lumpectomy Margin Width in Patients with Ductal Carcinoma In Situ

  • Local-Regional Evaluation and Therapy (EP Mamounas, Section Editor)
  • Published:
Current Breast Cancer Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Ductal carcinoma in situ (DCIS) can be successfully treated with breast-conserving surgery (BCS); however, there is little consensus regarding what negative margin width minimizes the risk of local recurrence, and as many as one third of patients undergo additional surgery after initial lumpectomy.

Recent Findings

An evidence-based SSO-ASTRO-ASCO consensus guideline on margin width for patients treated with BCS and whole breast irradiation found a margin width of 2 mm to be optimal, and that margins greater than 2 mm did not further reduce local recurrence rates. Multiple factors determine the need for re-excision in patients with negative margins less than 2 mm.

Summary

There has been much debate regarding the appropriate negative margin width after BCS for DCIS. The new consensus guideline has provided a standard negative margin definition which may reduce rates of re-excision.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Ernster VL, Ballard-Barbash R, Barlow WE, Zheng Y, Weaver DL, Cutter G, et al. Detection of ductal carcinoma in situ in women undergoing screening mammography. J Natl Cancer Inst. 2002;94(20):1546–54.

    Article  PubMed  Google Scholar 

  2. 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.

    Article  PubMed  Google Scholar 

  3. Worni M, Akushevich I, Greenup R, Sarma D, Ryser MD, Myers ER, et al. Trends in treatment patterns and outcomes for ductal carcinoma in situ. J Natl Cancer Inst. 2015;107(12):djv263.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Narod SA, Iqbal J, Giannakeas V, Sopik V, Sun P. Breast cancer mortality after a diagnosis of ductal carcinoma in situ. JAMA Oncol. 2015;1(7):888–96.

    Article  PubMed  Google Scholar 

  5. Stuart KE, Houssami N, Taylor R, Hayen A, Boyages J. Long-term outcomes of ductal carcinoma in situ of the breast: a systematic review, meta-analysis and meta-regression analysis. BMC Cancer. 2015;15:890.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Bijker N, Peterse JL, Duchateau L, Julien JP, Fentiman IS, Duval C, et al. Risk factors for recurrence and metastasis after breast-conserving therapy for ductal carcinoma-in-situ: analysis of European Organization for Research and Treatment of Cancer Trial 10853. J Clin Oncol. 2001;19(8):2263–71.

    Article  CAS  PubMed  Google Scholar 

  7. Wang SY, Shamliyan T, Virnig BA, Kane R. Tumor characteristics as predictors of local recurrence after treatment of ductal carcinoma in situ: a meta-analysis. Breast Cancer Res Treat. 2011;127(1):1–14.

    Article  CAS  PubMed  Google Scholar 

  8. Wapnir IL, Dignam JJ, Fisher B, Mamounas EP, Anderson SJ, Julian TB, et al. Long-term outcomes of invasive ipsilateral breast tumor recurrences after lumpectomy in NSABP B-17 and B-24 randomized clinical trials for DCIS. J Natl Cancer Inst. 2011;103(6):478–88.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Morrow M, Jagsi R, Alderman AK, Griggs JJ, Hawley ST, Hamilton AS, et al. Surgeon recommendations and receipt of mastectomy for treatment of breast cancer. JAMA. 2009;302(14):1551–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Emdin SO, Granstrand B, Ringberg A, Sandelin K, Arnesson LG, Nordgren H, et al. SweDCIS: radiotherapy after sector resection for ductal carcinoma in situ of the breast. Results of a randomised trial in a population offered mammography screening. Acta Oncol. 2006;45(5):536–43.

    Article  PubMed  Google Scholar 

  11. Fisher B, Dignam J, Wolmark N, Mamounas E, Costantino J, Poller W, et al. Lumpectomy and radiation therapy for the treatment of intraductal breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-17. J Clin Oncol. 1998;16(2):441–52.

    Article  CAS  PubMed  Google Scholar 

  12. Houghton J, George WD, Cuzick J, Duggan C, Fentiman IS, Spittle M, et al. Radiotherapy and tamoxifen in women with completely excised ductal carcinoma in situ of the breast in the UK, Australia, and New Zealand: randomised controlled trial. Lancet. 2003;362(9378):95–102.

    Article  PubMed  Google Scholar 

  13. Julien JP, Bijker N, Fentiman IS, Peterse JL, Delledonne V, Rouanet P, et al. Radiotherapy in breast-conserving treatment for ductal carcinoma in situ: first results of the EORTC randomised phase III trial 10853. EORTC Breast Cancer Cooperative Group and EORTC Radiotherapy Group. Lancet. 2000;355(9203):528–33.

    Article  CAS  PubMed  Google Scholar 

  14. 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(10):1615–20.

    Article  PubMed  Google Scholar 

  15. Wang SY, Chu H, Shamliyan T, Jalal H, Kuntz KM, Kane RL, et al. Network meta-analysis of margin threshold for women with ductal carcinoma in situ. J Natl Cancer Inst. 2012;104(7):507–16.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Azu M, Abrahamse P, Katz SJ, Jagsi R, Morrow M. What is an adequate margin for breast-conserving surgery? Surgeon attitudes and correlates. Ann Surg Oncol. 2010;17(2):558–63.

    Article  PubMed  Google Scholar 

  17. • Marinovich ML, Azizi L, Macaskill P, Irwig L, Morrow M, Solin LJ, et al. The association of surgical margins and local recurrence in women with ductal carcinoma in situ treated with breast-conserving therapy: a meta-analysis. Ann Surg Oncol. 2016;23(12):3811–21. Meta-analysis comprehensively reviewing the data on local recurrence related to margin widths for DCIS treated with breast conservation

    Article  PubMed  Google Scholar 

  18. • Morrow M, Van Zee KJ, Solin LJ, Houssami N, Chavez-MacGregor M, Harris JR, et al. Society of Surgical Oncology-American Society for Radiation Oncology-American Society of Clinical Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in ductal carcinoma in situ. Ann Surg Oncol. 2016;23(12):3801–10. SSO-ASTRO-ASCO consensus guidelines with recommendations on margin widths for DCIS based on extensive review of the literature

    Article  PubMed  PubMed Central  Google Scholar 

  19. Early Breast Cancer Trialists' Collaborative G, Correa C, McGale P, Taylor C, Wang Y, Clarke M, 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.

    Article  Google Scholar 

  20. • 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(4):623–31. Large study evaluating local recurrence for various margin width thresholds for DCIS treated with breast conservation with and without radiation

    PubMed  PubMed Central  Google Scholar 

  21. McCormick B, Winter K, Hudis C, Kuerer HM, Rakovitch E, Smith BL, et al. RTOG 9804: a prospective randomized trial for good-risk ductal carcinoma in situ comparing radiotherapy with observation. J Clin Oncol. 2015;33(7):709–15.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. • Solin LJ, Gray R, Hughes LL, Wood WC, Lowen MA, Badve SS, et al. Surgical excision without radiation for ductal carcinoma in situ of the breast: 12-year results from the ECOG-ACRIN E5194 Study. J Clin Oncol. 2015;33(33):3938–44. Prospective, multi-institutional study of excision alone in pre-defined low risk subset of DCIS patients

    Article  PubMed  PubMed Central  Google Scholar 

  23. Wong JS, Chen YH, Gadd MA, Gelman R, Lester SC, Schnitt SJ, et al. Eight-year update of a prospective study of wide excision alone for small low- or intermediate-grade ductal carcinoma in situ (DCIS). Breast Cancer Res Treat. 2014;143(2):343–50.

    Article  PubMed  Google Scholar 

  24. • Moran MS, Schnitt SJ, Giuliano AE, Harris JR, Khan SA, Horton J, 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 consensus guidelines with recommendations on margin widths for invasive cancer

    Article  PubMed  Google Scholar 

  25. Li Y, Zhang S, Wei X, Zhang J. The clinical features and management of women with ductal carcinoma in situ with microinvasion: a retrospective cohort study. Int J Surg. 2015;19:91–4.

    Article  CAS  PubMed  Google Scholar 

  26. Parikh RR, Haffty BG, Lannin D, Moran MS. Ductal carcinoma in situ with microinvasion: prognostic implications, long-term outcomes, and role of axillary evaluation. Int J Radiat Oncol Biol Phys. 2012;82(1):7–13.

    Article  PubMed  Google Scholar 

  27. Arvold ND, Taghian AG, Niemierko A, Abi Raad RF, Sreedhara M, Nguyen PL, et al. Age, breast cancer subtype approximation, and local recurrence after breast-conserving therapy. J Clin Oncol. 2011;29(29):3885–91.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Voduc KD, Cheang MC, Tyldesley S, Gelmon K, Nielsen TO, Kennecke H. Breast cancer subtypes and the risk of local and regional relapse. J Clin Oncol. 2010;28(10):1684–91.

    Article  PubMed  Google Scholar 

  29. Anderson SJ, Wapnir I, Dignam JJ, Fisher B, Mamounas EP, Jeong JH, et al. Prognosis after ipsilateral breast tumor recurrence and locoregional recurrences in patients treated by breast-conserving therapy in five National Surgical Adjuvant Breast and Bowel Project protocols of node-negative breast cancer. J Clin Oncol. 2009;27(15):2466–73.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Hind D, Ward S, De Nigris E, Simpson E, Carroll C, Wyld L. Hormonal therapies for early breast cancer: systematic review and economic evaluation. Health Technol Assess. 2007;11(26):iii-iv, ix-xi, 1–134.

  31. Mannino M, Yarnold JR. Local relapse rates are falling after breast conserving surgery and systemic therapy for early breast cancer: can radiotherapy ever be safely withheld? Radiother Oncol. 2009;90(1):14–22.

    Article  PubMed  Google Scholar 

  32. Smith I, Procter M, Gelber RD, Guillaume S, Feyereislova A, Dowsett M, et al. 2-year follow-up of trastuzumab after adjuvant chemotherapy in HER2-positive breast cancer: a randomised controlled trial. Lancet. 2007;369(9555):29–36.

    Article  CAS  PubMed  Google Scholar 

  33. Blair SL, Thompson K, Rococco J, Malcarne V, Beitsch PD, Ollila DW. Attaining negative margins in breast-conservation operations: is there a consensus among breast surgeons? J Am Coll Surg. 2009;209(5):608–13.

    Article  PubMed  Google Scholar 

  34. Parvez E, Hodgson N, Cornacchi SD, Ramsaroop A, Gordon M, Farrokhyar F, 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.

    Article  PubMed  Google Scholar 

  35. DeSnyder SM, Hunt KK, Smith BD, Moran MS, Klimberg S, Lucci A. Assessment of practice patterns following publication of the SSO-ASTRO consensus guideline on margins for breast-conserving therapy in stage I and II invasive breast cancer. Ann Surg Oncol. 2015;22(10):3250–6.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Chung A, Gangi A, Amersi F, Bose S, Zhang X, Giuliano A. Impact of consensus guidelines by the Society of Surgical Oncology and the American Society for Radiation Oncology on margins for breast-conserving surgery in stages 1 and 2 invasive breast cancer. Ann Surg Oncol. 2015;22(Suppl 3):S422–7.

    Article  PubMed  Google Scholar 

  37. Rosenberger LH, Mamtani A, Fuzesi S, Stempel M, Eaton A, Morrow M, et al. Early adoption of the SSO-ASTRO consensus guidelines on margins for breast-conserving surgery with whole-breast irradiation in stage I and II invasive breast cancer: initial experience from Memorial Sloan Kettering Cancer Center. Ann Surg Oncol. 2016;23(10):3239–46.

    Article  PubMed  Google Scholar 

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Acknowledgements

The preparation of this article was supported in part by NIH/NCI Cancer Center Support Grant No. P30 CA008748.

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Authors and Affiliations

  1. Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, 10065, USA

    Oriana Petruolo & Monica Morrow

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  1. Oriana Petruolo
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  2. Monica Morrow
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Correspondence to Monica Morrow.

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Oriana Petruolo and Monica Morrow declare that they have no conflict of interest.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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This article is part of the Topical Collection on Local-Regional Evaluation and Therapy

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Petruolo, O., Morrow, M. New Guidelines on the Adequacy of Lumpectomy Margin Width in Patients with Ductal Carcinoma In Situ. Curr Breast Cancer Rep 9, 122–128 (2017). https://doi.org/10.1007/s12609-017-0238-7

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  • DOI: https://doi.org/10.1007/s12609-017-0238-7

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