1
|
Bundred JR, Michael S, Stuart B, Cutress RI, Beckmann K, Holleczek B, Dahlstrom JE, Gath J, Dodwell D, Bundred NJ. Margin status and survival outcomes after breast cancer conservation surgery: prospectively registered systematic review and meta-analysis. BMJ 2022; 378:e070346. [PMID: 36130770 PMCID: PMC9490551 DOI: 10.1136/bmj-2022-070346] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine if margin involvement is associated with distant recurrence and to determine the required margin to minimise both local recurrence and distant recurrence in early stage invasive breast cancer. DESIGN Prospectively registered systematic review and meta-analysis of literature. DATA SOURCES Medline (PubMed), Embase, and Proquest online databases. Unpublished data were sought from study authors. ELIGIBILITY CRITERIA Eligible studies reported on patients undergoing breast conserving surgery (for stages I-III breast cancer), allowed an estimation of outcomes in relation to margin status, and followed up patients for a minimum of 60 months. Patients with ductal carcinoma in situ only or treated with neoadjuvant chemotherapy or by mastectomy were excluded. Where applicable, margins were categorised as tumour on ink (involved), close margins (no tumour on ink but <2 mm), and negative margins (≥2 mm). RESULTS 68 studies from 1 January 1980 to 31 December 2021, comprising 112 140 patients with breast cancer, were included. Across all studies, 9.4% (95% confidence interval 6.8% to 12.8%) of patients had involved (tumour on ink) margins and 17.8% (13.0% to 23.9%) had tumour on ink or a close margin. The rate of distant recurrence was 25.4% (14.5% to 40.6%) in patients with tumour on ink, 8.4% (4.4% to 15.5%) in patients with tumour on ink or close, and 7.4% (3.9% to 13.6%) in patients with negative margins. Compared with negative margins, tumour on ink margins were associated with increased distant recurrence (hazard ratio 2.10, 95% confidence interval 1.65 to 2.69, P<0.001) and local recurrence (1.98, 1.66 to 2.36, P<0.001). Close margins were associated with increased distant recurrence (1.38, 1.13 to 1.69, P<0.001) and local recurrence (2.09, 1.39 to 3.13, P<0.001) compared with negative margins, after adjusting for receipt of adjuvant chemotherapy and radiotherapy. In five studies published since 2010, tumour on ink margins were associated with increased distant recurrence (2.41, 1.81 to 3.21, P<0.001) as were tumour on ink and close margins (1.44, 1.22 to 1.71, P<0.001) compared with negative margins. CONCLUSIONS Involved or close pathological margins after breast conserving surgery for early stage, invasive breast cancer are associated with increased distant recurrence and local recurrence. Surgeons should aim to achieve a minimum clear margin of at least 1 mm. On the basis of current evidence, international guidelines should be revised. SYSTEMATIC REVIEW REGISTRATION CRD42021232115.
Collapse
Affiliation(s)
- James R Bundred
- Leeds Institute of Molecular Medicine, University of Leeds, Leeds, UK
- Leeds Institute of Emergency Surgery, St James University Hospital, Leeds, UK
| | - Sarah Michael
- Manchester University NHS Foundation Trust, Wythenshawe, Manchester, UK
- Division of Cancer sciences, University of Manchester, Manchester, UK
| | - Beth Stuart
- Cancer Sciences, University of Southampton, Southampton, UK
| | - Ramsey I Cutress
- Cancer Sciences, University of Southampton, Southampton, UK
- University Hospital Southampton, Southampton, UK
| | - Kerri Beckmann
- Cancer Epidemiology and Population Health Research Group, University of South Australia, Adelaide, SA, Australia
| | - Bernd Holleczek
- Division of Clinical Epidemiology Aging Research, German Cancer Research Centre (DKFZ), Heidelberg, Germany
- Saarland Cancer Registry, Saarbrücken, Germany
| | - Jane E Dahlstrom
- ACT Pathology, Canberra Health Services and Australian National University Medical School, ACT, Australia
| | - Jacqui Gath
- Independent Cancer Patients' Voice, London, UK
| | - David Dodwell
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Nigel J Bundred
- Manchester University NHS Foundation Trust, Wythenshawe, Manchester, UK
- Division of Cancer sciences, University of Manchester, Manchester, UK
| |
Collapse
|
2
|
Tamburelli F, Maggiorotto F, Marchiò C, Balmativola D, Magistris A, Kubatzki F, Sgandurra P, Di Virgilio MR, Regge D, Montemurro F, Gatti M, Sapino A, Ponzone R. Reoperation rate after breast conserving surgery as quality indicator in breast cancer treatment: A reappraisal. Breast 2020; 53:181-188. [PMID: 32841804 PMCID: PMC7451417 DOI: 10.1016/j.breast.2020.07.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 07/04/2020] [Accepted: 07/28/2020] [Indexed: 12/15/2022] Open
Abstract
Aim To analyse the role of repeated breast surgery (RBS) after breast conserving surgery (BCS) as a quality indicator in a consecutive series of breast cancer patients. Methods Data from 1233 breast cancer patients submitted to BCS from 2015 to 2019 were reviewed. The influence of several variables on RBS rate (182/1232; 14.8%) was examined. Univariate and multivariate analyses were conducted to look for significant associations with the risk of RBS. Results Surgical workload, BCS rate and clinicopathological variables were consistent over the study period, while RBS rate decreased after the introduction of shaving of cavity margins (from 17.9% to 9.5%). Tumor persistence at RBS was higher for mastectomy vs. re-excision (87.3% vs. 37.8%; p = 0.05), inconclusive vs. positive diagnostic biopsy (48.2% vs. 69.4%; p = 0.003), ductal carcinoma in situ vs. invasive carcinoma (69.0% vs. 51.3%; p = 0.046) and lower after neoadjuvant therapy (14.3% vs. 57.8%; p = 0.044). Several clinicopathological variables were associated with the risk of RBS, but only multifocality [Odds Ratio (OR): 1.8; p = 0.009], microcalcifications (OR: 2.0, p = 0.000), neoadjuvant therapy (OR: 0.4; p = 0.014), pathological intraoperative assessment (OR: 0.6; p = 0.010) and shaving of cavity margins (OR: 0.3; p = 0.000) retained independent value at multivariate analysis. Conclusions RBS rate can be reduced by shaving of cavity margins. Current standards for RBS should not be made more stringent due to the existence of non-actionable risk factors. The value of RBS as a quality indicator should be scrutinzed. Some breast cancer patients need a reoperation for incomplete tumor excision after breast conserving surgery. Reoperation rates show wide variations (10%–50%) among different Countries. Shaving of cavity margins may reduce the reoperation rate, but non-invasive and multicentric lesiona are non-actionable risk factors The value of reoperation rate as a quality indicator of breast cancer surgery is questionable.
Collapse
Affiliation(s)
- Francesca Tamburelli
- Gynecological Oncology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy
| | - Furio Maggiorotto
- Gynecological Oncology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy
| | - Caterina Marchiò
- Pathology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy; Department of Medical Sciences, University of Turin, 10126, Turin, Italy
| | - Davide Balmativola
- Pathology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy
| | - Alessandra Magistris
- Gynecological Oncology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy
| | - Franziska Kubatzki
- Gynecological Oncology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy
| | - Paola Sgandurra
- Gynecological Oncology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy
| | - Maria Rosaria Di Virgilio
- Radiology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy
| | - Daniele Regge
- Department of Surgical Sciences, University of Turin, 10124, Turin, Italy; Radiology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy
| | - Filippo Montemurro
- Multidisciplinary Outpatient Oncology Clinic, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy
| | - Marco Gatti
- Radiotherapy Unit, Candiolo Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy
| | - Anna Sapino
- Pathology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy; Department of Medical Sciences, University of Turin, 10126, Turin, Italy
| | - Riccardo Ponzone
- Gynecological Oncology Unit, Candiolo Cancer Institute, FPO - IRCCS, Strada Provinciale 142 Km 3.95, 10060, Candiolo, Italy.
| |
Collapse
|
3
|
Pahmeyer C, Schablack A, Ratiu D, Thangarajah F, Ludwig S, Gruettner B, Mallmann P, Malter W, Warm M, Eichler C. Occurrence of Residual Cancer Within Re-excisions After Subcutaneous Mastectomy of Invasive Breast Cancer and Ductal Carcinoma In Situ - A Retrospective Analysis. In Vivo 2020; 34:2015-2019. [PMID: 32606175 DOI: 10.21873/invivo.12000] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 04/17/2020] [Accepted: 04/18/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND/AIM Surgical margin status remains an important determinant for recurrence of invasive breast cancer and ductal carcinoma in situ. We compared the number of positive margins in initial histology with rates of residual tumor in re-excision specimens. Furthermore, we analysed cost-effectiveness of re-excisions. PATIENTS AND METHODS 101 patients treated with secondary surgery were included. The first group underwent breast conserving surgery and secondary mastectomy. The second group was primarily treated with subcutaneous mastectomy followed by secondary surgery. RESULTS Within the first group, 22.7% did not show residual tumor in the re-excision specimen. Of the second group, 54.3% had no residual tumor. Consequentially 45.7% needed a re-excision to achieve R0 status. Cost-effectiveness was determined as secondary endpoint. If a patient needs a secondary mastectomy the hospital gains 602,65€ in comparison to a primary breast conserving operation. CONCLUSION In every second patient who had first received a subcutaneous mastectomy, no tumor could be detected in the secondary operation despite a previous R1 status.
Collapse
Affiliation(s)
- Caroline Pahmeyer
- Department of Gynecology and Obstetrics, University of Cologne, Cologne, Germany
| | - Anika Schablack
- Department of Gynecology and Obstetrics, University of Cologne, Cologne, Germany
| | - Dominik Ratiu
- Department of Gynecology and Obstetrics, University of Cologne, Cologne, Germany
| | - Fabinshy Thangarajah
- Department of Gynecology and Obstetrics, University of Cologne, Cologne, Germany
| | - Sebastian Ludwig
- Department of Gynecology and Obstetrics, University of Cologne, Cologne, Germany
| | - Berthold Gruettner
- Department of Gynecology and Obstetrics, University of Cologne, Cologne, Germany
| | - Peter Mallmann
- Department of Gynecology and Obstetrics, University of Cologne, Cologne, Germany
| | - Wolfram Malter
- Department of Gynecology and Obstetrics, University of Cologne, Cologne, Germany
| | - Mathias Warm
- Breast Cancer Center, Municipal Hospital Holweide, Cologne, Germany
| | - Christian Eichler
- Department of Gynecology and Obstetrics, University of Cologne, Cologne, Germany
| |
Collapse
|
4
|
Boundouki G, Wong Sik Hee JR, Croghan N, Stocking K, Pieri A, Critchley A, Kirwan CC, Harvey JR. Comparing long-term local recurrence rates of surgical and non-surgical management of close anterior margins in breast conserving surgery. Breast Cancer Res Treat 2019; 176:311-319. [PMID: 31012033 DOI: 10.1007/s10549-019-05242-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 04/15/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE While it is known that histologically involved margins lead to a higher local recurrence rate, re-excision of anterior margins is less common than that of radial margins. However, there are minimal long-term data on the oncological safety of non-surgical management of anterior margins. PATIENTS AND METHODS A retrospective study was performed of all patients who underwent breast conserving surgery for breast cancer between 2000 and 2008 at two tertiary referral centres. A close margin was defined as disease within two mm of the resection margin (including disease at the margin). RESULTS 6922 patients underwent surgery for invasive or in situ breast cancer of whom 277 patients had a close anterior margin alone after breast conserving surgery. Two hundred and twenty patients had non-surgical management of their margins, while 57 had re-excision surgery. Overall, there were 4/57 local recurrences in the surgical management group and 12/220 in the non-surgical management group. The local recurrence-free survival rate at 5 years was 98.2% (1 recurrence, 95% CI 87.8-99.7) in the surgical management group and 97.2% (6 recurrences, 95% CI 93.8-98.7) in the non-surgical management group. At 10 years, the rates were 92.2% (4 recurrences, 95% CI 80.3-97.0) in the surgical management group and 93.9% (12 recurrences, 95% CI 89.4-96.5) in the non-surgical management group. There was no significant difference found in the local recurrence rate between management groups (HR 1.24, 95% CI 0.40, 3.85; p = 0.71). CONCLUSIONS Local recurrence rates are acceptable and similar in both the surgically and non-surgically managed groups. Non-surgical management of close anterior margins appears oncologically safe when combined with appropriate adjuvant therapy.
Collapse
Affiliation(s)
- George Boundouki
- Nightingale Breast Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK.
| | - Joseph Ryan Wong Sik Hee
- Nightingale Breast Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK
| | - Natalie Croghan
- Nightingale Breast Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK
| | - Katie Stocking
- Department of Medical Statistics, Manchester University NHS Foundation Trust, Manchester, UK
| | - Andrew Pieri
- Department of Breast Surgery, Royal Victoria Infirmary, Queen Victoria Road, Newcastle-upon-Tyne, NE1 4LP, UK
| | - Adam Critchley
- Department of Breast Surgery, Royal Victoria Infirmary, Queen Victoria Road, Newcastle-upon-Tyne, NE1 4LP, UK
| | - Cliona C Kirwan
- Nightingale Breast Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Cancer Research Centre, Manchester Academic Health Science Centre, University of Manchester, 555 Wilmslow Road, Manchester, M20 4GJ, UK
| | - James R Harvey
- Nightingale Breast Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Cancer Research Centre, Manchester Academic Health Science Centre, University of Manchester, 555 Wilmslow Road, Manchester, M20 4GJ, UK
| |
Collapse
|
5
|
Murugappan K, Saboo A, Kuo L, Ung O. Paradigm shift in the local treatment of breast cancer: mastectomy to breast conservation surgery. Gland Surg 2018; 7:506-519. [PMID: 30687624 PMCID: PMC6323252 DOI: 10.21037/gs.2018.09.01] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 09/03/2018] [Indexed: 01/16/2023]
Abstract
There have been fundamental changes in the approach to breast cancer management over the last century but the primary objective of achieving oncological safety remains unchanged. This evolution is highlighted with a summary of the key evidences in support of the oncological safety of breast conserving surgery (BCS) in early breast cancer (EBC) management. We will also discuss the increasingly pivotal role that neoadjuvant chemotherapy (NACT) may play, in the local treatment of EBC and locally advanced breast cancer (LABC) and the long-term surgical and oncological outcomes.
Collapse
Affiliation(s)
- Kowsi Murugappan
- Royal Brisbane Breast Surgery Unit, Department of General Surgery, RBWH, Brisbane, Australia
- University of Queensland, Brisbane, Australia
| | - Apoorva Saboo
- Royal Brisbane Breast Surgery Unit, Department of General Surgery, RBWH, Brisbane, Australia
| | - Lu Kuo
- University of Queensland, Brisbane, Australia
| | - Owen Ung
- Royal Brisbane Breast Surgery Unit, Department of General Surgery, RBWH, Brisbane, Australia
- University of Queensland, Brisbane, Australia
| |
Collapse
|
6
|
Lai HW, Huang RH, Wu YT, Chen CJ, Chen ST, Lin YJ, Chen DR, Lee CW, Wu HK, Lin HY, Kuo SJ. Clinicopathologic factors related to surgical margin involvement, reoperation, and residual cancer in primary operable breast cancer – An analysis of 2050 patients. Eur J Surg Oncol 2018; 44:1725-1735. [DOI: 10.1016/j.ejso.2018.07.056] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 07/04/2018] [Accepted: 07/23/2018] [Indexed: 12/23/2022] Open
|
7
|
Chen JY, Huang YJ, Zhang LL, Yang CQ, Wang K. Comparison of Oncoplastic Breast-Conserving Surgery and Breast-Conserving Surgery Alone: A Meta-Analysis. J Breast Cancer 2018; 21:321-329. [PMID: 30275861 PMCID: PMC6158154 DOI: 10.4048/jbc.2018.21.e36] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 07/11/2018] [Indexed: 12/28/2022] Open
Abstract
Purpose The use of oncoplastic reconstruction for breast-conserving surgery (BCS) extends benefits beyond merely minimizing poor cosmetic results. However, the feasibility and oncological safety of oncoplastic surgery (OPS) are controversial. Methods This meta-analysis aimed to compare the short-term and long-term oncological outcomes of BCS alone and BCS plus OPS. Relevant studies published before July 2017 in the Embase, the Cochrane Library, PubMed, and Web of Science databases were screened and collected. The meta-analysis was performed using STATA software (Stata Corp.). Results A total of 3,789 patients from 11 studies were included, with 2,691 patients in the BCS-alone group and 1,098 patients in the BCS plus OPS group. The demographics were similar between both groups, and no significant difference was observed in pathological T and N stages between the two groups. Re-excision was less common (relative risk [RR], 0.66; p=0.009) and the positive-margin rate was lower, but not significantly (RR, 0.83; p=0.191), in the BCS plus OPS group than in the BCS-alone group. The local and distal recurrence rates were similar in both groups. Both disease-free survival (hazard ratio [HR], 1.19; 95% confidence interval [CI], 0.96-1.49; p=0.112) and overall survival (HR, 1.14; 95% CI, 0.76-1.69; p=0.527) did not differ between the two groups. Conclusion A combination of BCS and OPS is preferred over BCS alone for decreasing re-excisions and provides similar long-term survival as BCS alone in patients with breast cancer.
Collapse
Affiliation(s)
- Jun-Ying Chen
- Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Yi-Jie Huang
- Department of General Surgery, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Liu-Lu Zhang
- Department of Breast Cancer, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Ci-Qiu Yang
- Department of Breast Cancer, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Kun Wang
- Department of Breast Cancer, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| |
Collapse
|
8
|
Präger M, Kiechle M, Stollenwerk B, Hinzen C, Glatz J, Vogl M, Leidl R. Costs and effects of intra-operative fluorescence molecular imaging - A model-based, early assessment. PLoS One 2018; 13:e0198137. [PMID: 29856875 PMCID: PMC5983425 DOI: 10.1371/journal.pone.0198137] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 05/14/2018] [Indexed: 11/25/2022] Open
Abstract
Introduction Successful breast conserving cancer surgeries come along with tumor free resection margins and account for cosmetic outcome. Positive margins increase the likelihood of tumor recurrence. Intra-operative fluorescence molecular imaging (IFMI) aims to focus surgery on malignant tissue thus substantially lowering the presence of positive margins as compared with standard techniques of breast conservation (ST). A goal of this paper is to assess the incremental number of surgeries and costs of IFMI vs. ST. Methods We developed a decision analytical model and applied it for an early evaluation approach. Given uncertainty we considered that IFMI might reduce the proportion of positive margins found by ST from all to none and this proportion is assumed to be reduced to 10% for the base case. Inputs included data from the literature and a range of effect estimates. For the costs of IFMI, respective cost components were added to those of ST. Results The base case reduction lowered number of surgeries (mean [95% confidence interval]) by 0.22 [0.15; 0.30] and changed costs (mean [95% confidence interval]) by €-663 [€-1,584; €50]. A tornado diagram identified the Diagnosis Related Group (DRG) costs, the proportion of positive margins of ST, the staff time saving factor and the duration of frozen section analysis (FSA) as important determinants of this cost. Conclusions These early results indicate that IFMI may be more effective than ST and through the reduction of positive margins it is possible to save follow-up surgeries–indicating further health risk–and to save costs through this margin reduction and the avoidance of FSA.
Collapse
Affiliation(s)
- Maximilian Präger
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München (GmbH)—German Research Center for Environmental Health, Neuherberg, Germany
- * E-mail:
| | - Marion Kiechle
- Center for Hereditary Breast and Ovarian Cancer, Department of Gynecology, Klinikum Rechts der Isar, Technical University Munich (TUM), Munich, Germany
- Comprehensive Cancer Center Munich (CCCM), Munich, Germany
| | - Björn Stollenwerk
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München (GmbH)—German Research Center for Environmental Health, Neuherberg, Germany
| | - Christoph Hinzen
- Institute of Biological and Medical Imaging, Helmholtz Zentrum München (GmbH)—German Research Center for Environmental Health, Neuherberg, Germany
- Chair for Biological Imaging, Technical University Munich, Munich, Germany
| | - Jürgen Glatz
- Institute of Biological and Medical Imaging, Helmholtz Zentrum München (GmbH)—German Research Center for Environmental Health, Neuherberg, Germany
- Chair for Biological Imaging, Technical University Munich, Munich, Germany
| | - Matthias Vogl
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München (GmbH)—German Research Center for Environmental Health, Neuherberg, Germany
| | - Reiner Leidl
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München (GmbH)—German Research Center for Environmental Health, Neuherberg, Germany
- Munich Center of Health Sciences, Ludwig-Maximilians-Universität München, Munich, Germany
| |
Collapse
|
9
|
Abstract
Breast-conserving surgery (BCS) followed by radiation therapy is the current standard of care for early stage breast cancer. Successful BCS necessitates complete tumor resection with clear margins at the pathologic assessment of the specimen ("no ink on tumor"). The presence of positive margins warrants additional surgery to obtain negative final margins, which has significant physical, psychological, and financial implications for the patient. The challenge lies in developing accurate real-time intraoperative margin assessment techniques to minimize the presence of "ink on tumor" and the subsequent need for additional surgery.
Collapse
|
10
|
Brouwer de Koning SG, Vrancken Peeters MJTFD, Jóźwiak K, Bhairosing PA, Ruers TJM. Tumor Resection Margin Definitions in Breast-Conserving Surgery: Systematic Review and Meta-analysis of the Current Literature. Clin Breast Cancer 2018; 18:e595-e600. [PMID: 29731404 DOI: 10.1016/j.clbc.2018.04.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 03/28/2018] [Accepted: 04/04/2018] [Indexed: 12/11/2022]
Abstract
Worldwide, various guidelines recommend what constitutes an adequate margin of excision for invasive breast cancer or for ductal carcinoma-in-situ (DCIS). We evaluated the use of different tumor resection margin guidelines and investigated their impact on positive margin rates (PMR) and reoperation rates (RR). Thirteen guidelines reporting on the extent of a positive margin were reviewed along with 31 studies, published between 2011 and 2016, reporting on a well-defined PMR. Studies were categorized according to the margin definition. Pooled PMR and RR were determined with random-effect models. For invasive breast cancer, most guidelines recommend a positive margin of tumor on ink. However, definitions of reported positive margins in the clinic vary from more than focally positive to the presence of tumor cells within 3 to 5 mm from the resection surface. Within the studies analyzed (59,979 patients), pooled PMRs for invasive breast cancer ranged from 9% to 36% and pooled RRs from 77% to 99%. For DCIS, guidelines vary between no DCIS on the resection surface to DCIS cells found within a distance of 2 mm from the resection edge. Pooled PMRs for DCIS varied from 4% to 23% (840 patients). Given the differences in tumor margin definition between countries worldwide, quality control data expressed as PMR or RR should be interpreted with caution. Furthermore, the overall definition for positive resection margins for both invasive disease and DCIS seems to have become more liberal.
Collapse
Affiliation(s)
| | | | - Katarzyna Jóźwiak
- Department of Epidemiology and Biostatistics, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Patrick A Bhairosing
- Scientific Information Service, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Theo J M Ruers
- Department of Surgery, The Netherlands Cancer Institute, Amsterdam, The Netherlands; MIRA Institute, University of Twente, Enschede, The Netherlands
| |
Collapse
|
11
|
Murphy BL, Boughey JC, Keeney MG, Glasgow AE, Racz JM, Keeney GL, Habermann EB. Factors Associated With Positive Margins in Women Undergoing Breast Conservation Surgery. Mayo Clin Proc 2018; 93:429-435. [PMID: 29439832 DOI: 10.1016/j.mayocp.2017.11.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 11/03/2017] [Accepted: 11/27/2017] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To identify factors predicting positive margins at lumpectomy prompting intraoperative reexcision in patients with breast cancer treated at a large referral center. PATIENTS AND METHODS We reviewed all breast cancer lumpectomy cases managed at our institution from January 1, 2012, through December 31, 2013. Associations between rates of positive margin and patient and tumor factors were assessed using χ2 tests and univariate and adjusted multivariate logistic regression, stratified by ductal carcinoma in situ (DCIS) or invasive cancer. RESULTS We identified 382 patients who underwent lumpectomy for definitive surgical resection of breast cancer, 102 for DCIS and 280 for invasive cancer. Overall, 234 patients (61.3%) required intraoperative reexcision for positive margins. The reexcision rate was higher in patients with DCIS than in those with invasive disease (78.4% [80 of 102] vs 56.4% [158 of 280]; univariate odds ratio, 2.80; 95% CI, 1.66-4.76; P<.001). Positive margin rates did not vary by patient age, surgeon, estrogen receptor, progesterone receptor, or ERBB2 status of the tumor. Among the 280 cases of invasive breast cancer, the only factor independently associated with lower odds of margin positivity was seed localization vs no localization (P=.03). CONCLUSION Ductal carcinoma in situ was associated with a higher rate of positive margins at lumpectomy than invasive breast cancer on univariate analysis. Within invasive disease, seed localization was associated with lower rates of margin positivity.
Collapse
MESH Headings
- Adult
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Female
- Humans
- Margins of Excision
- Mastectomy, Segmental
- Middle Aged
- Neoplasm Recurrence, Local/prevention & control
- Neoplasm Staging
- Neoplasm, Residual/prevention & control
- Retrospective Studies
- Risk Factors
Collapse
Affiliation(s)
- Brittany L Murphy
- Department of Surgery, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | | | - Michael G Keeney
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Amy E Glasgow
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | | | - Gary L Keeney
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Elizabeth B Habermann
- Department of Surgery, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
| |
Collapse
|
12
|
Adherence to guidelines and breast cancer patients survival: a population-based cohort study analyzed with a causal inference approach. Breast Cancer Res Treat 2017; 164:119-131. [DOI: 10.1007/s10549-017-4210-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 03/17/2017] [Indexed: 10/19/2022]
|
13
|
Mellon EA, Orman A, Joya LE, Montejo ME, Laronga C, Hoover SJ, Lee MC, Khakpour N, Kubal PF, Diaz R. Frequency of whole breast radiation therapy after intraoperative radiation therapy due to criteria identified by lumpectomy. Brachytherapy 2017; 16:174-180. [DOI: 10.1016/j.brachy.2016.09.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 09/29/2016] [Accepted: 09/30/2016] [Indexed: 11/16/2022]
|
14
|
Nooij LS, van der Slot MA, Dekkers OM, Stijnen T, Gaarenstroom KN, Creutzberg CL, Smit VTHBM, Bosse T, van Poelgeest MIE. Tumour-free margins in vulvar squamous cell carcinoma: Does distance really matter? Eur J Cancer 2016; 65:139-49. [PMID: 27497345 DOI: 10.1016/j.ejca.2016.07.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 06/29/2016] [Accepted: 07/04/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is no consensus on the width of tumour-free margins after surgery for vulvar squamous cell carcinoma (VSCC). Most current guidelines recommend tumour-free margins of ≥8 mm. The aim of this study was to investigate whether a margin of <8 mm is associated with an increased risk of local recurrence in VSCC. METHODS A meta-analysis of the available literature and a cohort study of 148 VSCC patients seen at a referral centre from 2000 to 2012 was performed. The primary end-point of the cohort study was a histologically confirmed ipsilateral local recurrence within 2 years after primary treatment in relation to the margin distance. RESULTS Based on 10 studies, the meta-analysis showed that a tumour-free margin of <8 mm is associated with a higher risk of local recurrence compared to a tumour-free margin of ≥8 mm (pooled risk ratio, 1.99 [95% confidence interval {CI}: 1.13-3.51], p = 0.02). In the cohort study, we found no clear difference in the risk of local recurrence in the <8 versus ≥8 mm group; however, 40% of the patients in the <8 mm group received additional treatment. Tumour-positive margin was the only independent risk factor for local recurrence in the multivariable analysis (hazard ratio, 0.21 [95% CI: 0.08-0.55]). CONCLUSIONS This work provides important data to question the commonly used 8-mm margin as a prognosticator for local recurrence. More research is needed to address the question of whether additional treatment improves the prognosis in patients with a tumour-free margin of <8 mm.
Collapse
Affiliation(s)
- L S Nooij
- Department of Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands; Department of Pathology, Leiden University Medical Centre, Leiden, The Netherlands
| | - M A van der Slot
- Department of Pathology, Leiden University Medical Centre, Leiden, The Netherlands
| | - O M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - T Stijnen
- Department of Medical Statistics, Leiden University Medical Centre, Leiden, The Netherlands
| | - K N Gaarenstroom
- Department of Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
| | - C L Creutzberg
- Department of Radiotherapy, Leiden University Medical Centre, Leiden, The Netherlands
| | - V T H B M Smit
- Department of Pathology, Leiden University Medical Centre, Leiden, The Netherlands
| | - T Bosse
- Department of Pathology, Leiden University Medical Centre, Leiden, The Netherlands
| | - M I E van Poelgeest
- Department of Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands.
| |
Collapse
|
15
|
Hanna J, Lannin D, Killelea B, Horowitz N, Chagpar AB. Factors Associated with Persistently Positive Margin Status after Breast-Conserving Surgery in Women with Breast Cancer: An Analysis of the National Cancer Database. Am Surg 2016. [DOI: 10.1177/000313481608200836] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Margin status after definitive breast-conserving surgery (BCS) is a key predictor of local tumor recurrence. This study utilized the National Cancer Database, which captures 70 per cent of all cancer cases nationally, to determine factors associated with persistently positive margins status post-BCS. From 1998 to 2010, there were 1,170,284 patients with stage 0 to 3 breast cancer who underwent BCS. After final definitive surgery, 7.3 per cent of patients had positive margins. On bivariate analysis, persistently positive margin status post-BCS was correlated with patient age, race, ethnicity, comorbidities, facility type and location, tumor size, grade, presence of invasive disease, lymph node positivity, as well as receipt of neoadjuvant chemotherapy and adjuvant radiation therapy ( P < 0.001). On multivariate analysis, patients who were black, with multiple comorbidities, living in a Pacific state, who had larger, high-grade, node-positive invasive tumors, who did not receive neoadjuvant chemotherapy, and who did not receive adjuvant radiation therapy were more likely to have persistently positive margins ( P < 0.05). Although the goal of BCS is the attainment of negative margins, 7.3 per cent of patients have persistently positive margins after definitive surgery. These patients tend to have more aggressive disease and greater comorbidities, and are less likely to receive adjuvant radiation therapy.
Collapse
Affiliation(s)
- Jonathan Hanna
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Donald Lannin
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Brigid Killelea
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Nina Horowitz
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Anees B. Chagpar
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| |
Collapse
|
16
|
Lai HW, Chen CJ, Lin YJ, Chen SL, Wu HK, Wu YT, Kuo SJ, Chen ST, Chen DR. Does Breast Magnetic Resonance Imaging Combined With Conventional Imaging Modalities Decrease the Rates of Surgical Margin Involvement and Reoperation?: A Case-Control Comparative Analysis. Medicine (Baltimore) 2016; 95:e3810. [PMID: 27258520 PMCID: PMC4900728 DOI: 10.1097/md.0000000000003810] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The objective of this study was to assess whether preoperative breast magnetic resonance imaging (MRI) combined with conventional breast imaging techniques decreases the rates of margin involvement and reexcision.Data on patients who underwent surgery for primary operable breast cancer were obtained from the Changhua Christian Hospital (CCH) breast cancer database. The rate of surgical margin involvement and the rate of reoperation were compared between patients who underwent conventional breast imaging modalities (Group A: mammography and sonography) and those who received breast MRI in addition to conventional imaging (Group B: mammography, sonography, and MRI).A total of 1468 patients were enrolled in this study. Among the 733 patients in Group A, 377 (51.4%) received breast-conserving surgery (BCS) and 356 (48.6%) received mastectomy. Among the 735 patients in Group B, 348 (47.3%) received BCS and 387 (52.7%) received mastectomy. There were no significant differences in operative method between patients who received conventional imaging alone and those that received MRI and conventional imaging (P = 0.13). The rate of detection of pathological multifocal/multicentric breast cancer was markedly higher in patients who received preoperative MRI than in those who underwent conventional imaging alone (14.3% vs 8.6%, P < 0.01). The overall rate of surgical margin involvement was significantly lower in patients who received MRI (5.0%) than in those who received conventional imaging alone (9.0%) (P < 0.01). However, a significant reduction in rate of surgical margin positivity was only observed in patients who received BCS (Group A, 14.6%; Group B, 6.6%, P < 0.01). The overall BCS reoperation rates were 11.7% in the conventional imaging group and 3.2% in the combined MRI group (P < 0.01). There were no significant differences in rate of residual cancer in specimens obtained during reoperation between the 2 preoperative imaging groups (Group A, 50%; Group B, 81.8%, P = 0.09). In multivariate analysis, multifocal/multicentric breast cancer (odds ratio = 2.38, P = 0.02) and without MRI use (odds ratio = 2.35, P < 0.01) were the major predisposing factors to margin involvement in patients received BCS.Preoperative breast MRI combined with conventional breast imaging results in a lower rate of surgical margin involvement and reoperations in patients who receive BCS.
Collapse
Affiliation(s)
- Hung-Wen Lai
- From the Endoscopic & Oncoplastic Breast Surgery Center (H-WL, S-LC, S-TC, D-RC), Comprehensive Breast Cancer Center (H-WL, S-LC, S-JK, S-TC, D-RC), Division of General Surgery, Department of Surgery (H-WL, S-JK, S-TC, D-RC), Department of Surgical Pathology (C-JC), Tumor Center (Y-JL), Department of Radiology, Changhua Christian Hospital, Changhua (H-KW), School of Medicine, National Yang Ming University, Taipei (H-WL), School of Medicine, Chung Shan Medical University, Taichung (C-JC), Department of Medical Technology, Jen-Teh Junior College of Medicine, Nursing and Management, Miaoli (C-JC), and Department of Surgery, Ministry of Healthy and Welfare Sinying Hospital, Tainan, Taiwan (Y-TW)
| | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Dixon J, Thomas J, Kerr G, Williams L, Dodds C, Kunkler I, Macaskill E. A study of margin width and local recurrence in breast conserving therapy for invasive breast cancer. Eur J Surg Oncol 2016; 42:657-64. [DOI: 10.1016/j.ejso.2016.02.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 01/26/2016] [Accepted: 02/02/2016] [Indexed: 10/22/2022] Open
|
18
|
A framework for the role of acute inflammation in tumor progression. Breast Cancer Res Treat 2015; 151:235-8. [DOI: 10.1007/s10549-015-3392-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 04/15/2015] [Indexed: 01/21/2023]
|
19
|
Clough KB, Benyahi D, Nos C, Charles C, Sarfati I. Oncoplastic Surgery: Pushing the Limits of Breast-Conserving Surgery. Breast J 2015; 21:140-6. [DOI: 10.1111/tbj.12372] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | | | - Claude Nos
- L'Institut du Sein - Paris Breast Center; Paris France
| | | | | |
Collapse
|