Skip to main content

Advertisement

SpringerLink
Log in

External validation and modification of nomogram for predicting positive resection margins before breast conserving surgery

  • Clinical trial
  • Published:
Breast Cancer Research and Treatment Aims and scope Submit manuscript

Abstract

Purpose

A positive resection margin after breast conserving surgery (BCS) is the most important risk factor for tumor recurrence. In 2012, Seoul National University Hospital (SNUH) breast surgery team developed a nomogram for predicting positive resection margins before BCS to provide individual surgical plans that could reduce local recurrence without increasing re-excision rates. The purpose of this study was to validate this nomogram using an external cohort and to test if addition of surgeon-related factor could improve its use as a predictive model.

Methods

A total of 419 patients with breast cancer who underwent BCS from January to December 2018 were retrospectively reviewed. Using the SNUH BCS nomogram, risk score for positive resection margins was calculated for 343 patients. The predictive accuracy of the nomogram was assessed, and multivariable logistic regression analyses were performed to evaluate the nomogram’s predictive variables.

Results

The positive resection margin rate of the current external validation cohort was 13.5% (46 out of 343), compared to 14.6% (151 out of 1034) of the original study. The discrimination power of the SNUH BCS nomogram as measure by area under the receiver operating characteristics curve (AUC) was 0.656 [95% confidence interval (CI) 0.576–0.735]. This result is lower than expected value of 0.823 [95% CI 0.785–0.862], the AUC of the original study. Multivariable logistic regression analysis showed that, among the five nomogram variables, presence of tumor size discrepancy greater than 0.5 cm between MRI and ultrasonography (OR 2.445, p = 0.019) and presence of ductal carcinoma in situ on needle biopsy (OR 2.066, p = 0.048) were significantly associated with positive resection margins. Finally, the nomogram score was re-calculated by adding each surgeon’s resection margin positive rate as odds ratio and the AUC was increased to 0.733.

Conclusions

Validation of the SNUH BCS nomogram was not successful in the current study as much as its original publication. However, we could improve its predictive power by including surgeon-related factor. Before applying a published nomogram as a preoperative predictive model, we suggest each institution to validate the model and adjust it with surgeon-related factor. Addition of new factors to currently available nomograms holds promise for improving its applicability for breast cancer patients at the actual clinical level.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Fisher B, Anderson S, Bryant J et al (2002) 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 347:1233–1241. https://doi.org/10.1056/NEJMoa022152

    Article  PubMed  Google Scholar 

  2. Veronesi U, Cascinelli N, Mariani L et al (2002) Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med 347:1227–1232. https://doi.org/10.1056/NEJMoa020989

    Article  PubMed  Google Scholar 

  3. Park CC, Mitsumori M, Nixon A et al (2000) Outcome at 8 years after breast-conserving surgery and radiation therapy for invasive breast cancer: influence of margin status and systemic therapy on local recurrence. J Clin Oncol 18:1668–1675. https://doi.org/10.1200/JCO.2000.18.8.1668

    Article  CAS  PubMed  Google Scholar 

  4. Houssami N, MacAskill P, Marinovich ML et al (2010) 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 46:3219–3232. https://doi.org/10.1016/j.ejca.2010.07.043

    Article  PubMed  Google Scholar 

  5. Zavagno G, Goldin E, Mencarelli R et al (2008) Role of resection margins in patients treated with breast conservation surgery. Cancer 112:1923–1931. https://doi.org/10.1002/cncr.23383

    Article  PubMed  Google Scholar 

  6. Patten CR, Walsh K, Sarantou T et al (2017) Changes in margin re-excision rates: Experience incorporating the “no ink on tumor” guideline into practice. J Surg Oncol 116:1040–1045. https://doi.org/10.1002/jso.24770

    Article  PubMed  Google Scholar 

  7. Van Zee KJ, Manasseh DME, Bevilacqua JLB et al (2003) A nomogram for predicting the likelihood of additional nodal metastases in breast cancer patients with a positive sentinel node biopsy. Ann Surg Oncol 10:1140–1151. https://doi.org/10.1245/ASO.2003.03.015

    Article  PubMed  Google Scholar 

  8. Poirier E, Sideris L, Dube P et al (2008) Analysis of clinical applicability of the breast cancer nomogram for positive sentinel lymph node: the Canadian experience. Ann Surg Oncol 15:2562–2567

    Article  Google Scholar 

  9. Alran S, De Rycke Y, Fourchotte V et al (2007) Validation and limitations of use of a breast cancer nomogram predicting the likelihood of non-sentinel node involvement after positive sentinel node biopsy. Ann Surg Oncol 14:2195–2201. https://doi.org/10.1245/s10434-006-9331-2

    Article  PubMed  Google Scholar 

  10. Lambert LA, Ayers GD, Hwang RF et al (2006) Validation of a breast cancer nomogram for predicting nonsentinel lymph node metastases after a positive sentinel node biopsy. Ann Surg Oncol 13:310–320

    Article  Google Scholar 

  11. Shin HC, Han W, Moon HG et al (2012) Nomogram for predicting positive resection margins after breast-conserving surgery. Breast Cancer Res Treat 134:1115–1123. https://doi.org/10.1007/s10549-012-2124-3

    Article  PubMed  Google Scholar 

  12. Agostinho JL, Zhao X, Sun W et al (2015) Prediction of positive margins following breast conserving surgery. Breast 24:46–50. https://doi.org/10.1016/j.breast.2014.11.001

    Article  PubMed  Google Scholar 

  13. Pleijhuis RG, Kwast ABG, Jansen L et al (2013) A validated web-based nomogram for predicting positive surgical margins following breast-conserving surgery as a preoperative tool for clinical decision-making. Breast 22:773–779. https://doi.org/10.1016/j.breast.2013.01.010

    Article  PubMed  Google Scholar 

  14. Rouzier R, Pusztai L, Garbay JR et al (2006) Development and validation of nomograms for predicting residual tumor size and the probability of successful conservative surgery with neoadjuvant chemotherapy for breast cancer. Cancer 107:1459–1466. https://doi.org/10.1002/cncr.22177

    Article  PubMed  Google Scholar 

  15. NCCN Guidelines Insights: Breast Cancer, Version 3.2018 in: Journal of the National Comprehensive Cancer Network Volume 17 Issue 2 (2019). https://jnccn.org/view/journals/jnccn/17/2/article-p118.xml?utm_source=TrendMD&utm_medium=cpc&utm_campaign=JNCCN_TrendMD_1. Accessed 10 Jun 2020

  16. Akobeng AK (2007) Understanding diagnostic tests 3: receiver operating characteristic curves. Acta Paediatr Int J Paediatr 96:644–647. https://doi.org/10.1111/j.1651-2227.2006.00178.x

    Article  Google Scholar 

  17. Fischer JE, Bachmann LM, Jaeschke R (2003) A readers’ guide to the interpretation of diagnostic test properties: clinical example of sepsis. Intensive Care Med 29:1043–1051

    Article  Google Scholar 

  18. Peintinger F (2011) Clinical use of nomograms for breast cancer. J Surg Oncol 103:745

    Article  Google Scholar 

  19. Klar M, Jochmann A, Foeldi M et al (2008) The MSKCC nomogram for prediction the likelihood of non-sentinel node involvement in a German breast cancer population. Breast Cancer Res Treat 112:523–531. https://doi.org/10.1007/s10549-007-9884-1

    Article  CAS  PubMed  Google Scholar 

  20. Pal A, Provenzano E, Duffy SW et al (2008) A model for predicting non-sentinel lymph node metastatic disease when the sentinel lymph node is positive. Br J Surg 95:302–309. https://doi.org/10.1002/bjs.5943

    Article  CAS  PubMed  Google Scholar 

  21. Soni NK, Carmalt HL, Gillett DJ, Spillane AJ (2005) Evaluation of a breast cancer nomogram for prediction of non-sentinel lymph node positivity. Eur J Surg Oncol 31:958–964. https://doi.org/10.1016/j.ejso.2005.04.011

    Article  CAS  PubMed  Google Scholar 

  22. Rahman GA (2011) Editorial: breast conserving therapy: a surgical technique where little can mean more. J Surg Tech Case Rep 3:1–4

    Article  CAS  Google Scholar 

  23. Sarin R, Somsekhar S, Kumar R et al (2018) Practical consensus recommendations for tumor margins and breast conservative surgery. South Asian J Cancer 7:72. https://doi.org/10.4103/sajc.sajc_105_18

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Azu M, Abrahamse P, Katz SJ et al (2010) What is an adequate margin for breast-conserving surgery? Surgeon attitudes and correlates. Ann Surg Oncol 17:558–563. https://doi.org/10.1245/s10434-009-0765-1

    Article  PubMed  Google Scholar 

  25. Taghian A, Mohiuddin M, Jagsi R et al (2005) Current perceptions regarding surgical margin status after breast-conserving therapy: results of a survey. Ann Surg 241:629–639

    Article  Google Scholar 

  26. Fisher B (2002) Twenty-year follow-up of a randomized trial comparing total for the treatment of invasive breast cancer. English J 347:1233–1241. https://doi.org/10.1056/NEJMoa020128

    Article  Google Scholar 

  27. Arriagada R, Lê MG, Rochard F, Contesso G (1996) Conservative treatment versus mastectomy in early breast cancer: patterns of failure with 15 years of follow-up data. J Clin Oncol 14:1558–1564. https://doi.org/10.1200/JCO.1996.14.5.1558

    Article  CAS  PubMed  Google Scholar 

  28. Moran MS, Schnitt SJ, Giuliano AE et al (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. Int J Radiat Oncol Biol Phys 88:553–564. https://doi.org/10.1016/j.ijrobp.2013.11.012

    Article  PubMed  PubMed Central  Google Scholar 

  29. Morrow M, Van Zee KJ, Solin LJ et al (2016) 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. J Clin Oncol 34:4040–4046. https://doi.org/10.1200/JCO.2016.68.3573

    Article  PubMed  PubMed Central  Google Scholar 

  30. Association of Breast Surgery at Baso (2009) (2009) Surgical guidelines for the management of breast cancer. Eur J Surg Oncol 35(Suppl 1):1–22. https://doi.org/10.1016/j.ejso.2009.01.008

    Article  Google Scholar 

  31. Bhutiani N, Mercer MK, Bachman KC et al (2018) Evaluating the effect of margin consensus guideline publication on operative patterns and financial impact of breast cancer operation. J Am Coll Surg 227:6–11. https://doi.org/10.1016/j.jamcollsurg.2018.01.050

    Article  PubMed  Google Scholar 

  32. Schulman AM, Mirrielees JA, Leverson G et al (2017) Reexcision surgery for breast cancer: an analysis of the American Society of Breast Surgeons (ASBrS) MasterySM database following the SSO-ASTRO “no ink on tumor” guidelines. Ann Surg Oncol 24:52–58. https://doi.org/10.1245/s10434-016-5516-5

    Article  PubMed  Google Scholar 

  33. Brouwer de Koning SG, Vrancken Peeters MJTFD, Jóźwiak K et al (2018) Tumor resection margin definitions in breast-conserving surgery: systematic review and meta-analysis of the current literature. Clin Breast Cancer 18:e595–e600

    Article  Google Scholar 

Download references

Acknowledgement

We greatly appreciate the active support of Division of Statistics in Medical Research Collaborating Center at Seoul National University Bundang Hospital for statistical analyses.

Author information

Author notes

  1. Ji-Jung Jung and Eun-Kyu Kim contributed equally.

Authors and Affiliations

  1. Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea

    Ji-Jung Jung, Eunyoung Kang, Eun-Kyu Kim & Hee-Chul Shin

  2. Department of Surgery, Seoul National University College of Medicine, Seoul, Korea

    Eunyoung Kang, Eun-Kyu Kim & Hee-Chul Shin

  3. Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea

    Sun Mi Kim, Mijung Jang & Bo La Yun

  4. Department of Pathology, Seoul National University Bundang Hospital, Seongnam, Korea

    So Yeon Park

Authors
  1. Ji-Jung Jung
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Eunyoung Kang
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Eun-Kyu Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Sun Mi Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Mijung Jang
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Bo La Yun
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. So Yeon Park
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Hee-Chul Shin
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Hee-Chul Shin.

Ethics declarations

Conflict of interest

None of the authors has a financial interest or commercial associations to declare in relation to the content of this article.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Jung, JJ., Kang, E., Kim, EK. et al. External validation and modification of nomogram for predicting positive resection margins before breast conserving surgery. Breast Cancer Res Treat 183, 373–380 (2020). https://doi.org/10.1007/s10549-020-05779-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10549-020-05779-z

Keywords

Search

Navigation