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Current Breast Cancer Reports

, Volume 8, Issue 2, pp 127–134 | Cite as

Margins in Breast-Conserving Surgery for Early Breast Cancer: How Much is Good Enough?

  • Nehmat HoussamiEmail author
  • M. Luke Marinovich
Local-Regional Evaluation and Therapy (EP Mamounas, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Local-Regional Evaluation and Therapy

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.

Keywords

Breast cancer Ductal carcinoma in situ Breast-conserving therapy Local recurrence Margins Meta-analysis Local–regional evaluation Early breast cancer Review 

Notes

Compliance with Ethical Standards

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.

References

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

  1. 1.
    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.CrossRefPubMedGoogle Scholar
  2. 2.
    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.CrossRefPubMedGoogle Scholar
  3. 3.
    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.CrossRefPubMedGoogle Scholar
  4. 4.
    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.CrossRefPubMedGoogle Scholar
  5. 5.
    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.CrossRefPubMedGoogle Scholar
  6. 6.
    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.CrossRefGoogle Scholar
  7. 7.
    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.Google Scholar
  8. 8.
    Newman LA, Kuerer HM. Advances in breast conservation therapy. J Clin Oncol. 2005;23(8):1685–97.CrossRefPubMedGoogle Scholar
  9. 9.
    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.Google Scholar
  10. 10.
    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.CrossRefPubMedGoogle Scholar
  11. 11.
    Singletary SE. Surgical margins in patients with early-stage breast cancer treated with breast conservation therapy. Am J Surg. 2002;184(5):383–93.CrossRefPubMedGoogle Scholar
  12. 12.•
    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.CrossRefPubMedGoogle Scholar
  13. 13.
    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.Google Scholar
  14. 14.
    Schwartz GF, Veronesi U, Clough KB, et al. Consensus conference on breast conservation. J Am Coll Surg. 2006;203(2):198–207.CrossRefPubMedGoogle Scholar
  15. 15.
    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.CrossRefPubMedGoogle Scholar
  16. 16.•
    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.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    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.CrossRefPubMedGoogle Scholar
  18. 18.•
    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.CrossRefPubMedGoogle Scholar
  19. 19.
    Morrow M. Margins in breast-conserving therapy: have we lost sight of the big picture? Expert Rev Anticancer Ther. 2008;8(8):1193–6.CrossRefPubMedGoogle Scholar
  20. 20.
    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.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    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.CrossRefPubMedGoogle Scholar
  22. 22.
    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.CrossRefPubMedGoogle Scholar
  23. 23.
    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.CrossRefGoogle Scholar
  24. 24.
    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)Google Scholar
  25. 25.
    Dixon JM, Houssami N. Bigger margins are not better in breast conserving surgery. BMJ. 2012;345, e5855.CrossRefPubMedGoogle Scholar
  26. 26.
    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.CrossRefGoogle Scholar
  27. 27.
    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.CrossRefPubMedGoogle Scholar
  28. 28.•
    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.CrossRefPubMedGoogle Scholar
  29. 29.•
    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.CrossRefGoogle Scholar
  30. 30.
    Dixon JM, Thomas J. In regard to Moran et al. Int J Rad Oncol Biol Phys. 2014;89(5):1139.CrossRefGoogle Scholar
  31. 31.
    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.CrossRefPubMedGoogle Scholar
  32. 32.
    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.CrossRefPubMedGoogle Scholar
  33. 33.
    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.CrossRefPubMedGoogle Scholar
  34. 34.
    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.CrossRefPubMedGoogle Scholar
  35. 35.
    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.CrossRefPubMedGoogle Scholar
  36. 36.
    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.CrossRefPubMedGoogle Scholar
  37. 37.
    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.CrossRefPubMedGoogle Scholar
  38. 38.
    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.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    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.CrossRefPubMedGoogle Scholar
  40. 40.
    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.CrossRefPubMedGoogle Scholar
  41. 41.
    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)
  42. 42.
    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.CrossRefGoogle Scholar
  43. 43.
    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.
  44. 44.
    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.
  45. 45.
    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.CrossRefPubMedGoogle Scholar
  46. 46.
    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.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    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.CrossRefPubMedGoogle Scholar
  48. 48.
    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.CrossRefPubMedGoogle Scholar
  49. 49.
    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.CrossRefPubMedGoogle Scholar
  50. 50.
    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.CrossRefPubMedGoogle Scholar
  51. 51.
    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.CrossRefPubMedGoogle Scholar
  52. 52.
    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.CrossRefPubMedGoogle Scholar
  53. 53.
    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.CrossRefPubMedGoogle Scholar
  54. 54.
    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.CrossRefPubMedGoogle Scholar
  55. 55.
    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.PubMedGoogle Scholar
  56. 56.
    Cataliotti L, Distante V, Ciatto S, et al. Intraductal breast cancer: review of 183 consecutive cases. Eur J Cancer. 1992;28:917–20.CrossRefGoogle Scholar
  57. 57.
    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.CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.•
    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.PubMedGoogle Scholar
  59. 59.
    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.CrossRefPubMedGoogle Scholar
  60. 60.
    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.CrossRefPubMedGoogle Scholar
  61. 61.
    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.CrossRefPubMedGoogle Scholar
  62. 62.
    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.CrossRefPubMedGoogle Scholar
  63. 63.
    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.CrossRefPubMedGoogle Scholar
  64. 64.
    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.CrossRefPubMedGoogle Scholar
  65. 65.
    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.CrossRefPubMedGoogle Scholar
  66. 66.
    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.CrossRefPubMedGoogle Scholar
  67. 67.
    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.CrossRefPubMedGoogle Scholar
  68. 68.
    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.CrossRefPubMedGoogle Scholar
  69. 69.
    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.CrossRefPubMedPubMedCentralGoogle Scholar
  70. 70.
    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.CrossRefPubMedGoogle Scholar
  71. 71.
    Morrow M, Katz SJ. Margins in ductal carcinoma in situ: is bigger really better? J Natl Cancer Inst. 2012;104(7):494–5.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  1. 1.School of Public Health, Sydney Medical SchoolUniversity of SydneySydneyAustralia

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