Skip to main content

Advertisement

Log in

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

Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

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.

Methods

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.

Results

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.

Conclusions

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.

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

Access this article

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

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

References

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  3. Hoover S, Bloom E, Patel S. Review of breast conservation therapy: then and now. ISRN Oncol. 2011;2011:617593.

    PubMed Central  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  PubMed Central  PubMed  Google Scholar 

  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.

    Article  PubMed Central  PubMed  Google Scholar 

  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.

    PubMed  Google Scholar 

  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.

    PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    PubMed Central  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    CAS  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  PubMed Central  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

Download references

Disclosure

The authors declare no conflict of interest.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Barbara L. Smith MD, PhD.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Merrill, A.L., Coopey, S.B., Tang, R. et al. Implications of New Lumpectomy Margin Guidelines for Breast-Conserving Surgery: Changes in Reexcision Rates and Predicted Rates of Residual Tumor. Ann Surg Oncol 23, 729–734 (2016). https://doi.org/10.1245/s10434-015-4916-2

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1245/s10434-015-4916-2

Keywords

Navigation