Awareness of residents’ technical ability can affect margin status in breast conserving operations

  • Joel VanderVelde
  • Jarvis W. Walters
  • Chiu-Hsieh Hsu
  • Elizabeth M. N. Ferguson
  • Jennifer Lee
  • Daniel M. Caruso
  • Ian K. KomenakaEmail author



The current study was performed to determine if awareness of the potential affect of residents could affect margin status.


Retrospective review of all patients who underwent lumpectomy from July 2006 to May 2017 was evaluated. The effect of surgical residents’ participation and their technical ability was evaluated to determine the effect on margin status. Logistic regression analysis was performed to determined factors which affect margin status.


Of 444 patients, 14% of patients had positive margins. The positive margin rate was lower during the second time period after the effect of technical ability of the residents was known 12% versus 19% (p = 0.10). Greater participation by the attending surgeon (32% vs. 21%) occurred in the second time period. In multivariate logistic regression analysis, operations done by residents with satisfactory technical skills or attending surgeon were less likely to have positive margins than those done by residents with unsatisfactory technical skills (OR 0.19, 95% CI 0.10–0.38; p = 0.0001). With mean follow-up of 48 months, 1.4% had local recurrences as a first event.


Technically ability of residents appears to affect margin status after lumpectomy. Increased intervention by the attending surgeon can improve this outcome.


Lumpectomy Breast conservation Margin Teaching Technical ability 


Compliance with ethical standards

Conflict of interest

All authors declare that they have no conflict of interest.

Ethical approval

This retrospective study was approved by the Institutional Review Board.

Research involving human and animal participants

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

Informed consent

Not applicable as this was a retrospective study.


  1. 1. Accessed 31 Dec 2018
  2. 2.
    Moran MS, Schnitt SJ, Giuliano AE, Harris JR, Khan SA, Horton J, Klimberg S, Chavez-MacGregor M, Freedman G, Houssami N, Johnson PL, Morrow M, Society of Surgical Oncology, American Society for Radiation Oncology (2014) 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 32(14):1507–1515. CrossRefPubMedGoogle Scholar
  3. 3.
    Singletary SE (2002) Surgical margins in patients with early-stage breast cancer treated with breast conservation therapy. Am J Surg 184(5):383–393CrossRefPubMedGoogle Scholar
  4. 4.
    Azu M, Abrahamse P, Katz SJ, Jagsi R, Morrow M (2010) What is an adequate margin for breast-conserving surgery? Surgeon attitudes and correlates. Ann Surg Oncol 17(2):558–563. CrossRefPubMedGoogle Scholar
  5. 5.
    Parvez E, Hodgson N, Cornacchi SD, Ramsaroop A, Gordon M, Farrokhyar F et al (2014) Survey of American and Canadian general surgeons’ perceptions of margin status and practice patterns for breast conserving surgery. Breast J 20(5):481–488. CrossRefPubMedGoogle Scholar
  6. 6.
    Chagpar AB, Killelea BK, Tsangaris TN, Butler M, Stavris K, Li F et al (2015) A randomized, controlled trial of cavity shave margins in breast cancer. N Engl J Med 373(6):503–510. CrossRefPubMedGoogle Scholar
  7. 7.
    Balch GC, Mithani SK, Simpson JF, Kelley MC (2005) Accuracy of intraoperative gross examination of surgical margin status in women undergoing partial mastectomy for breast malignancy. Am Surg 71(1):22–27PubMedGoogle Scholar
  8. 8.
    Bellon JR, Come SE, Gelman RS, Henderson IC, Shulman LN, Silver BJ et al (2005) Sequencing of chemotherapy and radiation therapy in early-stage breast cancer: updated results of a prospective randomized trial. J Clin Oncol 23(9):1934–1940CrossRefPubMedGoogle Scholar
  9. 9.
    Cochrane RA, Valasiadou P, Wilson AR, Al-Ghazal SK, Macmillan RD (2003) Cosmesis and satisfaction after breast-conserving surgery correlates with the percentage of breast volume excised. Br J Surg 90(12):1505–1509CrossRefPubMedGoogle Scholar
  10. 10.
    Wazer DE, DiPetrillo T, Schmidt-Ullrich R, Weld L, Smith TJ, Marchant DJ et al (1992) Factors influencing cosmetic outcome and complication risk after conservative surgery and radiotherapy for early-stage breast carcinoma. J Clin Oncol 10(3):356–363CrossRefPubMedGoogle Scholar
  11. 11.
    Abe SE, Hill JS, Han Y, Walsh K, Symanowski JT, Hadzikadic-Gusic L et al (2015) Margin re-excision and local recurrence in invasive breast cancer: a cost analysis using a decision tree model. J Surg Oncol 112(4):443–448. CrossRefPubMedGoogle Scholar
  12. 12.
    Gray RJ, Pockaj BA, Garvey E, Blair S (2018) Intraoperative margin management in breast-conserving surgery: a systematic review of the literature. Ann Surg Oncol 25(1):18–27. CrossRefPubMedGoogle Scholar
  13. 13.
    Cabioglu N, Hunt KK, Sahin AA, Kuerer HM, Babiera GV, Singletary SE et al (2007) Role for intraoperative margin assessment in patients undergoing breast-conserving surgery. Ann Surg Oncol 14(4):1458–1471CrossRefPubMedGoogle Scholar
  14. 14.
    Boughey JC, Hieken TJ, Jakub JW, Degnim AC, Grant CS, Farley DR et al (2014) Impact of analysis of frozen-section margin on reoperation rates in women undergoing lumpectomy for breast cancer: evaluation of the National Surgical Quality Improvement Program data. Surgery 156(1):190–197. CrossRefPubMedGoogle Scholar
  15. 15.
    Corsi F, Sorrentino L, Bonzini M, Bossi D, Truffi M, Amadori R et al (2017) Cavity shaving reduces involved margins and reinterventions without increasing costs in breast-conserving surgery: a propensity score-matched study. Ann Surg Oncol 24(6):1516–1524. CrossRefPubMedGoogle Scholar
  16. 16.
    Schnabel F, Boolbol SK, Gittleman M, Karni T, Tafra L, Feldman S et al (2014) A randomized prospective study of lumpectomy margin assessment with use of MarginProbe in patients with nonpalpable breast malignancies. Ann Surg Oncol 21(5):1589–1595. CrossRefPubMedGoogle Scholar
  17. 17.
    Cleffken B, Postelmans J, Olde Damink S, Nap M, Schreutelkamp I, van der Bijl H (2007) Breast-conserving therapy for palpable and nonpalpable breast cancer: can surgical residents do the job irrespective of experience? World J Surg 31(9):1731–1736CrossRefPubMedGoogle Scholar
  18. 18.
    Aguilar B, Sheikh F, Pockaj B, Wasif N, Gray R (2011) The effect of junior residents on surgical quality: a study of surgical outcomes in breast surgery. Am J Surg 202(6):654–657CrossRefPubMedGoogle Scholar
  19. 19.
    Tsigonis AM, Landercasper J, Al-Hamadani M, Linebarger JH, Vang CA, Johnson JM et al (2015) Are breast cancer outcomes compromised by general surgical resident participation in the operation? J Surg Educ 72(6):1109–1117. CrossRefPubMedGoogle Scholar
  20. 20.
    Shirah GR, Hsu CH, Heberer MA, Wikholm LI, Goodman JJ, Bouton ME et al (2016) Teaching residents may affect the margin status of breast-conserving operations. Surg Today 46(4):437–444. CrossRefPubMedGoogle Scholar
  21. 21.
    Peterson ME, Schultz DJ, Reynolds C, Solin LJ (1999) Outcomes in breast cancer patients relative to margin status after treatment with breast-conserving surgery and radiation therapy: the University of Pennsylvania experience. Int J Radiat Oncol Biol Phys 43(5):1029–1035CrossRefPubMedGoogle Scholar
  22. 22.
    Borger J, Kemperman H, Hart A, Peterse H, van Dongen J, Bartelink H (1994) Risk factors in breast-conservation therapy. J Clin Oncol 12(4):653–660CrossRefPubMedGoogle Scholar
  23. 23.
    Zork NM, Komenaka IK, Pennington RE Jr, Bowling MW, Norton LE, Clare SE et al (2008) The effect of dedicated breast surgeons on the short-term outcomes in breast cancer. Ann Surg 248(2):280–285CrossRefPubMedGoogle Scholar
  24. 24.
    Torabi R, Hsu CH, Patel PN, Dave H, Bouton ME, Komenaka IK (2013) Predictors of margin status after breast-conserving operations in an underscreened population. Langenbecks Arch Surg 398(3):455–462CrossRefPubMedGoogle Scholar
  25. 25.
    Gurdal SO, Ozcinar B, Kayahan M, Igci A, Tunaci M, Ozmen V et al (2013) Incremental value of magnetic resonance imaging for breast surgery planning. Surg Today 43(1):55–61CrossRefPubMedGoogle Scholar
  26. 26.
    Conway RG, Bartlett EK, Hoffman RL, Czerniecki BJ, Karakousis GC, Kelz RR (2015) Residents’ experience in breast cancer care. J Surg Educ 72(6):12339. CrossRefGoogle Scholar
  27. 27.
    Moorthy K, Asopa V, Wiggins E, Callam M (2004) Is the reexcision rate higher if breast conservation surgery is performed by surgical trainees? Am J Surg 188(1):45–48CrossRefPubMedGoogle Scholar
  28. 28.
    Carty MJ, Chan R, Huckman R, Snow D, Orgill DP (2009) A detailed analysis of the reduction mammaplasty learning curve: a statistical process model for approaching surgical performance improvement. Plast Reconstr Surg 124(3):706–714CrossRefPubMedGoogle Scholar
  29. 29.
    Hogg ME, Zenati M, Novak S, Chen Y, Jun Y, Steve J et al (2016) Grading of surgeon technical performance predicts postoperative pancreatic fistula for pancreaticoduodenectomy independent of patient-related variables. Ann Surg 264(3):482–491CrossRefPubMedGoogle Scholar
  30. 30.
    Birkmeyer JD, Finks JF, O’Reilly A, Oerline M, Carlin AM, Nunn AR et al (2013) Surgical skill and complication rates after bariatric surgery. N Engl J Med 369(15):1434–1442CrossRefPubMedGoogle Scholar
  31. 31.
    Hu YY, Peyre SE, Arriaga AF, Osteen RT, Corso KA, Weiser TG et al (2012) Postgame analysis: using video-based coaching for continuous professional development. J Am Coll Surg 214(1):115–124CrossRefPubMedGoogle Scholar
  32. 32.
    Dimick JB, Scott JW (2019) A video is worth a thousand operative notes. JAMA Surg. Google Scholar
  33. 33.
    Gurdal SO, Ozcinar B, Kayahan M, Igci A, Tunaci M, Ozmen V et al (2013) Incremental value of magnetic resonance imaging for breast surgery planning. Surg Today 43(1):55–61CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of SurgeryMaricopa Medical CenterPhoenixUSA
  2. 2.Arizona Cancer Center, University of ArizonaTucsonUSA
  3. 3.Mel and Enid Zuckerman Arizona College of Public HealthUniversity of ArizonaTucsonUSA
  4. 4.Arizona State UniversityPhoenixUSA

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