Abstract
Purpose
Risk factors for local recurrence (LR) following breast-conserving therapy (BCT) inform the need for local therapy. A Danish population-based cohort study identified residual disease on reexcision as an independent risk factor for LR but was limited by incomplete data on biologic subtype (Bodilsen et al. 2015 in Ann Surg Oncol 22: S476–S485). We sought to elaborate this risk in an independent cohort with clearly defined biologic subtypes.
Methods
The study population included patients with localized invasive breast cancer with complete biologic subtype data treated with BCT with one or zero reexcisions at one institution from 1998 to 2008. Cumulative incidence of LR was calculated using competing risk analysis, and associated risk factors were evaluated using Cox proportional hazards regression.
Results
A total 1073 consecutive patients were included with a median follow-up of 10 years. The 10-year LR rates were 2.4% [95% confidence interval (CI) 1.4–3.9%] without reexcision, 6.0% (95% CI 3.8–8.9%) with reexcision, and 8.2% (95% CI 4.1–14.0%) with any reexcised residual disease. On univariate regression, residual disease [hazard ratio (HR) = 1.50, p = 0.31] was not significantly associated with LR. Subtype other than luminal A/luminal-HER2 (luminal B HR = 2.29, p = 0.033; HER2/triple-negative HR = 2.85, p = 0.004), age (HR = 0.95 per year, p < 0.001), and nodal involvement (HR = 1.12 per involved node, p = 0.001) remained significant on multivariate regression. The impact of residual disease was confounded by its association (p < 0.001) with nodal involvement.
Conclusions
Our findings suggest that LR is associated with younger age, nodal involvement, and biologic subtype but not with residual disease at reexcision. The study’s power is limited by the low incidence of LR despite detailed clinical data and long-term follow-up. Further study is required.
Similar content being viewed by others
References
Bodilsen A, Bjerre K, Offersen BV, et al. The influence of repeat surgery and residual disease on recurrence after breast-conserving surgery: a Danish Breast Cancer Cooperative Group Study. Ann Surg Oncol. 2015;22 Suppl 3:S476–85.
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.
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.
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.
Aziz D, Rawlinson E, Narod SA, et al. The role of reexcision for positive margins in optimizing local disease control after breast-conserving surgery for cancer. Breast J. 2006;12(4):331–7.
Kotwall C, Ranson M, Stiles A, Hamann MS. Relationship between initial margin status for invasive breast cancer and residual carcinoma after re-excision. Am Surg. 2007;73(4):337–43.
McCahill LE, Single RM, Aiello Bowles EJ, et al. Variability in reexcision following breast conservation surgery. JAMA. 2012;307(5):467–75.
Morrow M, Jagsi R, Alderman AK, et al. Surgeon recommendations and receipt of mastectomy for treatment of breast cancer. JAMA. 2009;302(14):1551–6.
Waljee JF, Hu ES, Newman LA, Alderman AK. Predictors of re-excision among women undergoing breast-conserving surgery for cancer. Ann Surg Oncol. 2008;15(5):1297–303.
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, 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.
Adams BJ, Zoon CK, Stevenson C, Chitnavis P, Wolfe L, Bear HD. The role of margin status and reexcision in local recurrence following breast conservation surgery. Ann Surg Oncol. 2013;20(7):2250–5.
Menes TS, Tartter PI, Bleiweiss I, Godbold JH, Estabrook A, Smith SR. The consequence of multiple re-excisions to obtain clear lumpectomy margins in breast cancer patients. Ann Surg Oncol. 2005;12(11):881–5.
O’Sullivan MJ, Li T, Freedman G, Morrow M. The effect of multiple reexcisions on the risk of local recurrence after breast conserving surgery. Ann Surg Oncol. 2007;14(11):3133–40.
Ali AN, Vapiwala N, Guo M, Hwang WT, Harris EE, Solin LJ. The impact of re-excision and residual disease on local recurrence after breast conservation treatment for patients with early stage breast cancer. Clin Breast Cancer. 2011;11(6):400–5.
Kouzminova NB, Aggarwal S, Aggarwal A, Allo MD, Lin AY. Impact of initial surgical margins and residual cancer upon re-excision on outcome of patients with localized breast cancer. Am J Surg. 2009;198(6):771–80.
Hattangadi-Gluth JA, Wo JY, Nguyen PL, et al. Basal subtype of invasive breast cancer is associated with a higher risk of true recurrence after conventional breast-conserving therapy. Int J Radiat Oncol Biol Phys. 2012;82(3):1185–91.
Russo AL, Arvold ND, Niemierko A, et al. Margin status and the risk of local recurrence in patients with early-stage breast cancer treated with breast-conserving therapy. Breast Cancer Res Treat. 2013;140(2):353–61.
Tseng YD, Uno H, Hughes ME, et al. Biological subtype predicts risk of locoregional recurrence after mastectomy and impact of postmastectomy radiation in a large national database. Int J Radiat Oncol Biol Phys. 2015;93(3):622–30.
Arvold ND, Taghian AG, Niemierko A, et al. Age, breast cancer subtype approximation, and local recurrence after breast-conserving therapy. J Clin Oncol. 2011;29(29):3885–91.
Gonzalez-Angulo AM, Litton JK, Broglio KR, et al. High risk of recurrence for patients with breast cancer who have human epidermal growth factor receptor 2-positive, node-negative tumors 1 cm or smaller. J Clin Oncol. 2009;27(34):5700–6.
Albert JM, Gonzalez-Angulo AM, Guray M, et al. Estrogen/progesterone receptor negativity and HER2 positivity predict locoregional recurrence in patients with T1a,bN0 breast cancer. Int J Radiat Oncol Biol Phys. 2010;77(5):1296–302.
Caudle AS, Yu TK, Tucker SL, et al. Local-regional control according to surrogate markers of breast cancer subtypes and response to neoadjuvant chemotherapy in breast cancer patients undergoing breast conserving therapy. Breast Cancer Res. 2012;14(3):R83.
Swisher SK, Vila J, Tucker SL, et al. Locoregional control according to breast cancer subtype and response to neoadjuvant chemotherapy in breast cancer patients undergoing breast-conserving therapy. Ann Surg Oncol. 2016;23(3):749–56.
Chism DB, Freedman GM, Li T, Anderson PR. Re-excision of margins before breast radiation-diagnostic or therapeutic? Int J Radiat Oncol Biol Phys. 2006;65(5):1416–21.
Halevy A, Lavy R, Pappo I, et al. Indication for relumpectomy—a useful scoring system in cases of invasive breast cancer. J Surg Oncol. 2012;105(4):376–80.
Jaffre I, Campion L, Dejode M, et al. Margin width should not still enforce a systematic surgical re-excision in the conservative treatment of early breast infiltrative ductal carcinoma. Ann Surg Oncol. 2013;20(12):3831–8.
Carey LA, Perou CM, Livasy CA, et al. Race, breast cancer subtypes, and survival in the Carolina Breast Cancer Study. JAMA. 2006;295(21):2492–502.
Perou CM, Sorlie T, Eisen MB, et al. Molecular portraits of human breast tumours. Nature. 2000;406(6797):747–52.
Sorlie T, Perou CM, Tibshirani R, et al. Gene expression patterns of breast carcinomas distinguish tumor subclasses with clinical implications. Proc Natl Acad Sci U S A. 2001;98(19):10869–74.
Disclosures
The authors have no relevant commercial interests or financial or material support to disclose.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Mihalcik, S.A., Rawal, B., Braunstein, L.Z. et al. The Impact of Reexcision and Residual Disease on Local Recurrence Following Breast-Conserving Therapy. Ann Surg Oncol 24, 1868–1873 (2017). https://doi.org/10.1245/s10434-016-5727-9
Received:
Published:
Issue Date:
DOI: https://doi.org/10.1245/s10434-016-5727-9