Annals of Surgical Oncology

, Volume 23, Issue 3, pp 729–734 | Cite as

Implications of New Lumpectomy Margin Guidelines for Breast-Conserving Surgery: Changes in Reexcision Rates and Predicted Rates of Residual Tumor

  • Andrea L. Merrill
  • Suzanne B. Coopey
  • Rong Tang
  • Maureen P. McEvoy
  • Michele C. Specht
  • Kevin S. Hughes
  • Michelle A. Gadd
  • Barbara L. SmithEmail author
Breast Oncology



The 2014 guidelines endorsed by Society of Surgical Oncology, the American Society of Breast Surgeons, and the American Society for Radiation Oncology advocate “no ink on tumor” as the new margin requirement for breast-conserving therapy (BCT). We used our lumpectomy margins database from 2004 to 2006 to predict the effect of these new guidelines on BCT.


Patients with neoadjuvant therapy, pure ductal carcinoma-in situ, or incomplete margin data were excluded. We applied new (“no ink on tumor”) and old (≥2 mm) margin guidelines and compared rates of positive margins, reexcision, and rates of residual disease found at reexcision.


A total of 437 lumpectomy surgeries met the eligibility criteria. Eighty-six percent had invasive ductal carcinoma, 12 % invasive lobular carcinoma, and 2 % invasive ductal carcinoma and invasive lobular carcinoma. Using a ≥2 mm margin standard, 36 % of lumpectomies had positive margins compared to 18 % using new guidelines (p < 0.0001). Seventy-seven percent of patients with “ink on tumor” had residual disease found at reexcision. Fifty percent of subjects with margins <2 mm had residual disease (p = 0.0013) but would not have undergone reexcision under the new guidelines. With margins of ≥2 mm, residual tumor was seen in the shaved margins of 14 % of lumpectomies. Residual tumor was more common in reexcisions for ductal carcinoma-in situ <2 mm from a margin than for invasive cancer (53 vs. 40 %), although this was not statistically significant.


Use of new lumpectomy margin guidelines would have reduced reoperation for BCT by half in our patient cohort. However, residual disease was present in many patients who would not have been reexcised with the new guidelines. Long-term follow-up of local recurrence rates is needed to determine if this increase in residual disease is clinically significant.


Residual Disease Invasive Ductal Carcinoma Positive Margin Local Recurrence Rate Invasive Lobular Carcinoma 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



The authors declare no conflict of interest.


  1. 1.
    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;347:1233–41.CrossRefPubMedGoogle Scholar
  2. 2.
    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;347:1227–32.CrossRefPubMedGoogle Scholar
  3. 3.
    Hoover S, Bloom E, Patel S. Review of breast conservation therapy: then and now. ISRN Oncol. 2011;2011:617593.PubMedCentralPubMedGoogle Scholar
  4. 4.
    Sarrazin D, Le MG, Arriagada R, et al. Ten-year results of a randomized trial comparing a conservative treatment to mastectomy in early breast cancer. Radiother Oncol. 1989;14:177–84.CrossRefPubMedGoogle Scholar
  5. 5.
    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
  6. 6.
    Tartter PI, Kaplan J, Bleiweiss I, et al. Lumpectomy margins, reexcision, and local recurrence of breast cancer. Am J Surg. 2000;179:81–5.CrossRefPubMedGoogle Scholar
  7. 7.
    Gage I, Schnitt SJ, Nixon AJ, et al. Pathologic margin involvement and the risk of recurrence in patients treated with breast-conserving therapy. Cancer. 1996;78:1921–8.CrossRefPubMedGoogle Scholar
  8. 8.
    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;17:558–63.PubMedCentralCrossRefPubMedGoogle Scholar
  9. 9.
    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;241:629–39.PubMedCentralCrossRefPubMedGoogle Scholar
  10. 10.
    Gupta A, Subhas G, Dubay L, et al. Review of re-excision for narrow or positive margins of invasive and intraductal carcinoma. Am Surg. 2010;76:731–4.PubMedGoogle Scholar
  11. 11.
    Sanchez C, Brem RF, McSwain AP, Rapelyea JA, Torrente J, Teal CB. Factors associated with re-excision in patients with early-stage breast cancer treated with breast conservation therapy. Am Surg. 2010;76:331–4.PubMedGoogle Scholar
  12. 12.
    Halasz LM, Sreedhara M, Chen YH, et al. Improved outcomes of breast-conserving therapy for patients with ductal carcinoma in situ. Int J Radiat Oncol Biol Phys. 2012;82:e581–6.CrossRefPubMedGoogle Scholar
  13. 13.
    Unzeitig A, Kobbermann A, Xie XJ, et al. Influence of surgical technique on mastectomy and reexcision rates in breast-conserving therapy for cancer. Int J Surg Oncol. 2012;2012:725121.PubMedCentralPubMedGoogle Scholar
  14. 14.
    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 Radiat Oncol Biol Phys. 2014;88:553–64.CrossRefPubMedGoogle Scholar
  15. 15.
    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;21:704–16.CrossRefPubMedGoogle Scholar
  16. 16.
    Chagpar AB, Killelea BK, Tsangaris TN, et al. A randomized, controlled trial of cavity shave margins in breast cancer. N Engl J Med. 2015;373(6):503–10.CrossRefPubMedGoogle Scholar
  17. 17.
    Holland R, Veling SH, Mravunac M, Hendriks JH. Histologic multifocality of tis, T1–2 breast carcinomas. Implications for clinical trials of breast-conserving surgery. Cancer. 1985;56:979–90.CrossRefPubMedGoogle Scholar
  18. 18.
    Bartelink H, Horiot JC, Poortmans P, et al. Recurrence rates after treatment of breast cancer with standard radiotherapy with or without additional radiation. N Engl J Med. 2001;345:1378–87.CrossRefPubMedGoogle Scholar
  19. 19.
    Bartelink H, Horiot JC, Poortmans PM, et al. Impact of a higher radiation dose on local control and survival in breast-conserving therapy of early breast cancer: 10-year results of the randomized boost versus no boost EORTC 22881-10882 trial. J Clin Oncol. 2007;25:3259–65.CrossRefPubMedGoogle Scholar
  20. 20.
    Romestaing P, Lehingue Y, Carrie C, et al. Role of a 10-Gy boost in the conservative treatment of early breast cancer: results of a randomized clinical trial in Lyon, France. J Clin Oncol. 1997;15:963–8.PubMedGoogle Scholar
  21. 21.
    Bartelink H, Maingon P, Poortmans P, et al. Whole-breast irradiation with or without a boost for patients treated with breast-conserving surgery for early breast cancer: 20-year follow-up of a randomised phase 3 trial. Lancet Oncol. 2015;16:47–56.CrossRefPubMedGoogle Scholar
  22. 22.
    McCormick B, Winter K, Hudis C, et al. RTOG 9804: a prospective randomized trial for good-risk ductal carcinoma in situ comparing radiotherapy with observation. J Clin Oncol. 2015;33:709–15.CrossRefPubMedGoogle Scholar
  23. 23.
    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;27:5319–24.PubMedCentralCrossRefPubMedGoogle Scholar
  24. 24.
    Wong JS, Chen YH, Gadd MA, 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;143:343–50.CrossRefPubMedGoogle Scholar
  25. 25.
    Hughes KS, Schnaper LA, Bellon JR, et al. Lumpectomy plus tamoxifen with or without irradiation in women age 70 years or older with early breast cancer: long-term follow-up of CALGB 9343. J Clin Oncol. 2013;31:2382–7.PubMedCentralCrossRefPubMedGoogle Scholar
  26. 26.
    Whelan TJ, Pignol JP, Levine MN, et al. Long-term results of hypofractionated radiation therapy for breast cancer. N Engl J Med. 2010;362:513–20.CrossRefPubMedGoogle Scholar

Copyright information

© Society of Surgical Oncology 2015

Authors and Affiliations

  • Andrea L. Merrill
    • 1
  • Suzanne B. Coopey
    • 1
  • Rong Tang
    • 1
    • 2
  • Maureen P. McEvoy
    • 1
  • Michele C. Specht
    • 1
  • Kevin S. Hughes
    • 1
  • Michelle A. Gadd
    • 1
  • Barbara L. Smith
    • 1
    Email author
  1. 1.Division of Surgical Oncology, Gillette Center for Women’s CancersMassachusetts General HospitalBostonUSA
  2. 2.Division of Breast Surgery, Hunan Cancer HospitalThe Affiliated Tumor Hospital of Xiangya Medical School of Central South UniversityChangshaChina

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