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Association of Surgical Margin Status with Oncologic Outcome in Patients Treated with Breast-Conserving Surgery. Curr Oncol 2022; 29:9271-9283. [PMID: 36547140 PMCID: PMC9777347 DOI: 10.3390/curroncol29120726] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 11/18/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
Abstract
We aimed to compare the prognosis of patients with close resection margins after breast-conserving surgery (BCS) with that of patients with negative margins and identified predictors of residual disease. A total of 542 patients with breast cancer who underwent BCS between 2003 and 2019 were selected and divided into the close margin (114 patients) and negative margin (428 patients) groups. The median follow-up period was 72 (interquartile range, 42-113) months. Most patients received radiation therapy (RTx) and systemic therapy according to their stage and molecular subtype. The 10-year locoregional recurrence-free survival rates of the close and negative margin groups were 88.2% and 95.5%, respectively (p = 0.001). Multivariable analysis showed that adjuvant RTx and margin status after definitive surgery were significantly associated with locoregional recurrence. Of the 57 patients who underwent re-excision, 34 (59.6%) had residual disease. Multivariable analysis revealed that a histological type of positive or close margins and multifocality were independent predictive factors for residual disease. Although the current guidelines suggest that no ink on tumor is an adequate margin after BCS, a close resection margin may be associated with locoregional failure. The treatment strategy for close resection margins after BCS should be based on individual clinicopathological features.
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Eaglehouse YL, Georg MW, Jatoi I, Shriver CD, Zhu K. Factors related to re-excision procedures following primary breast-conserving surgery for women with breast cancer in the U.S. Military Health System. J Surg Oncol 2020; 121:200-209. [PMID: 31784990 DOI: 10.1002/jso.25788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 11/17/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND AND OBJECTIVES Re-excision surgery is undertaken to obtain clear margins after breast-conserving surgery (BCS) for localized breast cancer. This study examines patient and tumor characteristics related to re-excision surgery in the universal-access Military Health System (MHS). METHODS Retrospective analysis of patients with pathologically confirmed stage I-III breast cancer between 1998 and 2014 in the Department of Defense Central Cancer Registry and MHS Data Repository-linked databases who received primary BCS. Multivariable stepwise logistic regression methods identified characteristics associated with re-excision surgery (lumpectomy and mastectomy) and conversion to mastectomy, given as adjusted odds ratios (AOR) and 95% confidence intervals (CIs). RESULTS Of 7637 women receiving BCS, 26.3% had a re-excision and 9.9% converted to mastectomy. Tumor location, larger tumor size (≥4 cm), and regional lymph node involvement were associated with a greater likelihood of re-excision and mastectomy conversion. Pathology before BCS (AOR, 0.39; 95% CI, 0.35, 0.44 for re-excision) and neoadjuvant treatment (AOR, 0.50; 95% CI, 0.36, 0.69 for re-excision) were associated with a decreased likelihood of these outcomes. Additionally, age, tumor histology, and military-specific variables were associated with mastectomy conversion. CONCLUSION Comprehensive preoperative workup, including tumor pathology, may better inform surgical decision-making and reduce re-excision rates.
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Affiliation(s)
- Yvonne L Eaglehouse
- Murtha Cancer Center Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Department of Surgery, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Matthew W Georg
- Murtha Cancer Center Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Ismail Jatoi
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Craig D Shriver
- Murtha Cancer Center Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Department of Surgery, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Kangmin Zhu
- Murtha Cancer Center Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland.,Department of Preventive Medicine and Biostatistics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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3
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O'Connell L, Walsh S, Evoy D, O'Doherty A, Quinn C, Rothwell J, Geraghty J, McDermott EW, Prichard R. The approach to an isolated close anterior margin in breast conserving surgery. Ann R Coll Surg Engl 2019; 101:268-272. [PMID: 30855173 DOI: 10.1308/rcsann.2019.0017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Although close radial margins after breast-conserving surgery routinely undergo re-excision, appropriate management of patients with close anterior margins remains a topic of controversy. An increasing body of literature suggests that re-excision of close anterior margins yields low rates of residual malignancy and may only be necessary in selected patients. The aim of this study was to examine the management of close anterior margins after breast conserving surgery in a single institution and to analyse the rate of residual disease in re-excised anterior margins. METHODS All patients having breast conserving surgery at St Vincent's University Hospital from January 2008 to December 2012 were reviewed retrospectively. Data collected included patient demographics, tumour characteristics, margin positivity, re-excision rates and definitive histology of the re-excision specimens. A close margin was defined as les than 2 mm. RESULTS A total of 930 patients were included with an average age of 65 years (range 29-94 years). Of these, 121 (13%) had a close anterior margin. Further re-excison of the anterior margin was carried out in 37 patients (30.6%) and a further 16 (13.2%) proceeded to mastectomy. Residual disease was found in 18.5% (7/36) of those who underwent re-excision and 7/16 (43.75%) of those who underwent mastectomy. Overall, 11.57% (14/121) of patients with close anterior margins were subsequently found to have residual disease. CONCLUSION The low yield of residual disease in re-excised anterior margins specimens supports the concept that routine re-excision of close anterior margins is not necessary. Further research is required to definitively assess its influence on the risk of local recurrence.
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Affiliation(s)
- L O'Connell
- Department of Breast, Endocrine and General Surgery, St Vincent's University Hospital , Dublin , Ireland
| | - S Walsh
- Department of Breast, Endocrine and General Surgery, St Vincent's University Hospital , Dublin , Ireland
| | - D Evoy
- Department of Breast, Endocrine and General Surgery, St Vincent's University Hospital , Dublin , Ireland
| | - A O'Doherty
- Department of Radiology, St Vincent's University Hospital , Dublin , Ireland
| | - C Quinn
- Department of Pathology, St Vincent's University Hospital , Dublin , Ireland
| | - J Rothwell
- Department of Breast, Endocrine and General Surgery, St Vincent's University Hospital , Dublin , Ireland
| | - J Geraghty
- Department of Breast, Endocrine and General Surgery, St Vincent's University Hospital , Dublin , Ireland
| | - E W McDermott
- Department of Breast, Endocrine and General Surgery, St Vincent's University Hospital , Dublin , Ireland
| | - R Prichard
- Department of Breast, Endocrine and General Surgery, St Vincent's University Hospital , Dublin , Ireland
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Kahlert S, Kolben TM, Schmoeckel E, Czogalla B, Hester A, Degenhardt T, Kempf C, Mahner S, Harbeck N, Kolben T. Prognostic impact of residual disease in simultaneous additional excision specimens after one-step breast conserving therapy with negative final margin status in primary breast cancer. Eur J Surg Oncol 2018; 44:1318-1323. [PMID: 30041974 DOI: 10.1016/j.ejso.2018.06.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 06/06/2018] [Accepted: 06/18/2018] [Indexed: 12/22/2022] Open
Abstract
PURPOSE The purpose of this study was the evaluation of risk factors for local recurrence after breast conserving surgery (BCS) with special focus on the impact of residual disease in specimens of simultaneous additional excisions (AE) from the tumor cavity on patients' outcome in patients with negative final margin status after one-step BCS. METHODS This study was designed as a single center retrospective cohort study. Patients with primary non-metastatic breast cancer treated by one-step BCS with pathologically confirmed negative resection status between 1990 and 2006 were included. Ipsilateral breast tumor recurrence (IBTR) and overall survival (OS) were evaluated by Kaplan-Meier-estimates. A multivariate Cox proportional hazards regression model was used to identify potential independent prognostic factors associated with the risk of IBTR. RESULTS A total of 1081 patients were included in this analysis. Simultaneous additional excisions were performed in 79.4% of patients (tumor positive: 12.2%). Median follow-up after primary diagnosis was 124 months. The IBTR rate after 15 years was significantly higher in the group with tumor positive AE (no AE (10.2%) vs. AE tumor positive (27.5%) p = 0.002; AE tumor negative (14.0%) vs. AE tumor positive (27.5%) p = 0.008). The OS rate did not differ significantly between groups. Multivariate analysis revealed residual cancer in AE being associated with a significantly increased relative risk of IBTR of 2.0 (p = 0.014). CONCLUSION In the current analysis residual disease in simultaneous additional excisions was associated with an increased risk for IBTR despite negative final margin status. This should be considered in the overall therapeutic concept.
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Affiliation(s)
- Steffen Kahlert
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, 15, 81377 Munich, Germany
| | - Theresa M Kolben
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, 15, 81377 Munich, Germany
| | - Elisa Schmoeckel
- Department of Pathology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Bastian Czogalla
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, 15, 81377 Munich, Germany
| | - Anna Hester
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, 15, 81377 Munich, Germany
| | - Tom Degenhardt
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, 15, 81377 Munich, Germany
| | - Cordula Kempf
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, 15, 81377 Munich, Germany
| | - Sven Mahner
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, 15, 81377 Munich, Germany
| | - Nadia Harbeck
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, 15, 81377 Munich, Germany
| | - Thomas Kolben
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, 15, 81377 Munich, Germany.
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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.
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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
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6
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Chagpar AB, Tsangaris TN, Lannin DR. Do All Positive Margins in Breast Cancer Patients Undergoing a Partial Mastectomy Need to Be Resected? J Am Coll Surg 2018. [PMID: 29524664 DOI: 10.1016/j.jamcollsurg.2018.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Positive margins have been reported in 20% to 40% of patients undergoing a partial mastectomy, often resulting in re-excision. How often the re-excision yields additional cancer and whether there are predictors of residual disease remain unknown. STUDY DESIGN Patients who had a positive margin (defined as tumor at ink for patients with invasive disease or within 1 mm for patients with ductal carcinoma in situ) in the SHAVE (A Randomized Controlled Trial of Routine Shave Margins Versus Standard Partial Mastectomy in Breast Cancer Patients) trial before randomization were evaluated to determine the rate of additional disease either in cavity shave margins or at re-excision. Details of the SHAVE trial can be found elsewhere. RESULTS Of the 235 patients in the trial, 82 (34.9%) had a positive margin before randomization; 58 of these patients underwent either cavity shave margins excision or a re-excision of the positive margin(s). Twenty-one (36.2%) patients had residual disease. On bivariate analysis, residual disease was associated with younger patient age (median 51 vs 62 years; p = 0.007), and the presence of high-grade ductal carcinoma in situ (57.1% vs 31.3% for grade 2 and 0% for grade 1; p = 0.025). The following factors were not associated with further disease: patient race; ethnicity; BMI; volume of resection; number of positive margins; extent of ductal carcinoma in situ; and extent, grade, and histologic subtype of invasive cancer. On multivariate analysis, only patient age younger than 60 years remained a significant predictor of residual disease (odds ratio 3.920; 95% CI 1.081 to 14.220; p = 0.038). CONCLUSIONS Positive margins are associated with further disease in more than one-third of patients and, aside from young age, there are no predictors of this. These findings support continued re-excision of positive margins, particularly in patients younger than 60 years of age.
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Affiliation(s)
- Anees B Chagpar
- Department of Surgery, Yale University School of Medicine, New Haven, CT.
| | | | - Donald R Lannin
- Department of Surgery, Yale University School of Medicine, New Haven, CT
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Vos EL, Gaal J, Verhoef C, Brouwer K, van Deurzen CHM, Koppert LB. Focally positive margins in breast conserving surgery: Predictors, residual disease, and local recurrence. Eur J Surg Oncol 2017; 43:1846-1854. [PMID: 28688723 DOI: 10.1016/j.ejso.2017.06.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 05/30/2017] [Accepted: 06/06/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Re-excision after breast conserving surgery (BCS) for invasive breast cancer (IBC) can be omitted for focally positive margins in the Netherlands, but this guideline is not routinely followed. Focally positive and extensively positive margins have rarely been studied separately and compared to negative margins regarding clinicopathological predictors, residual disease incidence, and local recurrence. METHODS All females with BCS for Tis-T3, without neo-adjuvant chemotherapy between 2005 and 2014 at one university hospital were included. Clinicopathological and follow-up information was collected from electronic patient records. Index tumor samples from all patients with re-excision were reviewed by one pathologist. Margins were classified as negative (≥2 mm width), close (<2 mm width), focally positive (≤4 mm length of tumor touching inked margin), or extensively positive (>4 mm length). RESULTS From 499 patients included, 212 (43%) had negative, 161 (32%) had close, 59 (12%) had focally positive, and 67 (13%) had extensively positive margins. Increasingly involved margins were associated with lobular type, tumor size, and adjacent DCIS in IBC patients and lesion size in purely DCIS patients. In IBC patients, 17%, 49%, and 77% had re-excision after close, focally positive, and extensively positive margins and residual disease incidence was 55%, 50%, and 70% respectively. In purely DCIS patients, 26 (65%), 13 (87%), and 16 (94%) had re-excision after close, focally positive, and extensively positive margins and residual disease incidence was 39%, 46%, and 90% respectively. CONCLUSION Incidence of residual disease after focally positive margins was not different from close margins, but was significantly higher after extensively positive margins. We recommend quantifying extent of margin involvement in all pathology reports.
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Affiliation(s)
- E L Vos
- Department of Surgery, Erasmus MC Cancer Institute, PO Box 5201, 3008 AE, Rotterdam, The Netherlands
| | - J Gaal
- Department of Pathology, Erasmus MC, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - C Verhoef
- Department of Surgery, Erasmus MC Cancer Institute, PO Box 5201, 3008 AE, Rotterdam, The Netherlands
| | - K Brouwer
- Department of Surgery, Erasmus MC Cancer Institute, PO Box 5201, 3008 AE, Rotterdam, The Netherlands
| | - C H M van Deurzen
- Department of Pathology, Erasmus MC, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - L B Koppert
- Department of Surgery, Erasmus MC Cancer Institute, PO Box 5201, 3008 AE, Rotterdam, The Netherlands.
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8
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Clinical benefit of nomogram for predicting positive resection margins in breast conserving surgery. Eur J Surg Oncol 2016; 42:1169-75. [DOI: 10.1016/j.ejso.2016.04.058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 04/01/2016] [Accepted: 04/18/2016] [Indexed: 11/20/2022] Open
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Rubio I, Ahmed M, Kovacs T, Marco V. Margins in breast conserving surgery: A practice-changing process. Eur J Surg Oncol 2016; 42:631-40. [DOI: 10.1016/j.ejso.2016.01.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 01/18/2016] [Indexed: 11/17/2022] Open
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Karanlik H, Ozgur I, Sahin D, Fayda M, Onder S, Yavuz E. Intraoperative ultrasound reduces the need for re-excision in breast-conserving surgery. World J Surg Oncol 2015; 13:321. [PMID: 26596699 PMCID: PMC4657358 DOI: 10.1186/s12957-015-0731-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 11/06/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The purpose of this study was to evaluate ultrasound-guided surgery for palpable breast cancer by comparing the standard palpation-guided surgery in terms of the extent of healthy breast tissue resection, the percentage of tumor-free margins, and cosmetic outcomes. METHODS This was a prospective, observational cohort study conducted from January 2009 to July 2011. Breast cancer patients, diagnosed via biopsy, were operated in guidance with either ultrasound or palpation. Patient demographics, tumor features, intraoperative findings, pathologic and cosmetic results, intraoperative-measured ultrasound margins, and pathology margins were compared. RESULTS Ultrasound (US)-guided lumpectomy was performed on 84 women and palpation-guided lumpectomy on 80 women. Patient demographics and tumor characteristics showed no differences. The rate of re-excision was 17 % for the palpation-guided surgery group, and 6 % for the US-guided group (p = 0.03). There was good correlation between the closest margins recorded by US and pathology margins (r = 0.76, p = 0.01). Volume of resection was significantly larger in the palpation-guided group despite the similar size of tumors (p = 0.048). Cosmetic outcome of surgery was equivalent between groups. CONCLUSIONS Intraoperative ultrasound guidance for excision of palpable breast cancers is feasible and gives results in terms of pathologic margins that are comparable with those achieved by standard palpation-guided excisions.
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Affiliation(s)
- Hasan Karanlik
- Surgical Oncology Unit, Institute of Oncology, Istanbul University, Istanbul, Turkey.
| | - Ilker Ozgur
- Department of General Surgery, Acibadem International Hospital, Bakirkoy, Istanbul, Turkey
| | - Dilek Sahin
- Department of Radiology, Institute of Oncology, Istanbul University, Istanbul, Turkey
| | - Merdan Fayda
- Department of Radiation Oncology, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Semen Onder
- Department of Pathology, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Ekrem Yavuz
- Department of Pathology, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
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Bernardi S, Bertozzi S, Londero AP, Gentile G, Angione V, Petri R. Influence of surgical margins on the outcome of breast cancer patients: a retrospective analysis. World J Surg 2015; 38:2279-87. [PMID: 24819382 DOI: 10.1007/s00268-014-2596-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Breast-conserving surgery has become the preferred treatment for early breast cancer. Yet the question of what constitutes a 'safe margin', in terms of impact on patient outcome, remains unanswered. Our aim was to address this knowledge gap by determining the prevalence of positive and narrow margins after breast-conserving surgery, and evaluating how margin status impacted local recurrence and overall survival. MATERIALS AND METHODS We collected data about all women who underwent breast-conserving cancer surgery in our department between 2002 and 2011, focusing on patient and tumor characteristics, the distance from the tumor to the surgical margin, therapies administered, and outcome (measured in terms of local recurrence and overall survival). Data were analyzed by R (version 3.0.1), considering p < 0.05 as significant. Multivariate analyses were also performed. RESULTS Of 1,192 women who received breast-conserving surgery, 264 were considered for widening; 111 of these patients had positive margins and 153 narrow (where narrow was defined as less than 5 mm). Widening was performed for 38 % of these patients (99/264) and mastectomy for 27 % (70/264), while 36 % (95/264) had no further surgery and were simply followed-up. Our multivariate analysis confirmed that local tumor recurrence and overall survival were not significantly influenced by margin status, either at initial surgery, or (for those patients with initially positive margins) at secondary margin-widening surgery. However, the following were found to be significantly correlated with local recurrence: tumor multifocality, high expression of Ki-67/Mib-1, comedo-like necrosis, and non-axillary lymph node positivity (p < 0.05). CONCLUSIONS We found the status of resection margins and the management of infiltrated or narrow margins to have no significant influence on local tumor recurrence rates or on overall patient survival. Instead, biological factors connected with tumor aggressiveness seem to play the most important role in breast cancer prognosis, independent of surgical radicality.
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Affiliation(s)
- Sergio Bernardi
- Department of General Surgery, AOU "SSMM della Misericordia", p.le SSMM Misericordia 15, 33100, Udine, Italy
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Bodilsen A, Bjerre K, Offersen BV, Vahl P, Ejlertsen B, Overgaard J, Christiansen P. The Influence of Repeat Surgery and Residual Disease on Recurrence After Breast-Conserving Surgery: A Danish Breast Cancer Cooperative Group Study. Ann Surg Oncol 2015; 22 Suppl 3:S476-85. [DOI: 10.1245/s10434-015-4707-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Indexed: 12/21/2022]
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Clough KB, Gouveia PF, Benyahi D, Massey EJD, Russ E, Sarfati I, Nos C. Positive Margins After Oncoplastic Surgery for Breast Cancer. Ann Surg Oncol 2015; 22:4247-53. [PMID: 25893409 DOI: 10.1245/s10434-015-4514-3] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND Oncoplastic techniques applied to breast-conserving surgery (BCS) allow large-volume resections without compromising cosmetic results. Level II oncoplastic techniques are based on mammoplasties. When required, they allow resection of more than 20 % of the breast volume; however, a subgroup of these patients will still have positive margins. The clinical management of positive margins after level II oncoplastic surgery (OPS) is a challenge. METHODS All patients who had undergone level II oncoplastic techniques at The Paris Breast Center between 2004 and 2013 were reviewed. The choice of the optimal mammoplasty technique was based on the tumor location and the 'quadrant per quadrant atlas'. RESULTS A total of 277 level II oncoplastic techniques were performed on 272 patients. The mean tumor size was 26 mm (range 2-160 mm), with a mean resected weight of 175 g (range 50-1540 g). The rate of positive margins was 11.9 %. Risk factors for positive margins identified in univariate analysis were histologic subgroup, tumor size, T stage and grade. In multivariate analysis, only patients with invasive lobular carcinoma had a significantly higher risk of positive margins. A second operation was required in 33 cases, and a third operation was required in three cases because of positive margins. Final breast conservation rate was 91 %. CONCLUSIONS Level II OPS results in a low positive margin rate despite large tumor size. Patients with involved margins can be offered a second BCS if the remaining volume allows this.
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Affiliation(s)
| | | | | | | | | | | | - Claude Nos
- L'Institut du Sein - Paris Breast Center, Paris, France
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14
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Houssami N, Morrow M. Margins in breast conservation: a clinician's perspective and what the literature tells us. J Surg Oncol 2014; 110:2-7. [PMID: 24756965 DOI: 10.1002/jso.23594] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 01/20/2014] [Indexed: 11/06/2022]
Abstract
The optimal margin in breast-conserving surgery is controversial, and re-excision is common. Pathologic margin assessment is not standardized, and tumor biology and the use of systemic therapy have a major impact on local control. A study-level meta-analysis found no difference in local recurrence for margin widths of 1, 2, and 5 mm, leading a multidisciplinary panel to recommend adoption of no ink on tumor as the standard definition of a negative margin.
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Affiliation(s)
- Nehmat Houssami
- Screening and Test Evaluation Program (STEP), School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia; Royal Hospital for Women, Sydney, Australia
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15
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Özmen V. Breast Cancer in Turkey: Clinical and Histopathological Characteristics (Analysis of 13.240 Patients). THE JOURNAL OF BREAST HEALTH 2014; 10:98-105. [PMID: 28331652 DOI: 10.5152/tjbh.2014.1988] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 01/06/2014] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Breast cancer is the most common type of cancer and the leading cause of cancer related deaths in women in Turkey, as elsewhere around the world. However, detailed and systematic demographics, data on clinical and pathological characteristics, and treatment were largely unavailable in Turkey until now. This paper is intended to provide an analysis of clinical and pathological data on women registered in the National Breast Cancer Database (Ulusal Meme Kanseri Veri Tabanı [UMKVT]), established within Turkish Federation of Breast Diseases Societies (TMHDF) and available for use in Turkey since 2005. MATERIALS AND METHODS Clinical and pathological data on breast cancer patients registered online in the database from May 01, 2005 to May 01, 2011 were investigated. Parameters examined in patients included age, menopausal status, distribution of clinical and pathological stage, histological type, tumor diameter, histological grades, regional lymphatic stage, estrogen (ER), progesterone (PR), HER-2 receptors and molecular subtypes. Analysis results of these parameters were compared with literature data and discussed. RESULTS A total of 13,240 patients with breast cancer since April 07, 1992 were included in the study, and 99% of them were female. Female breast cancer patients whose requisite parameters had been completely entered in the database were included in the analysis. The mean age was 51.6 years (±12.6; range 12-97), 17% of them were younger than 40 years of age, and 45% were premenopausal. According to an analysis of age groups at diagnosis, the frequency of cancer peaked at the 45 - 49 age group with 16.7%, declining to 7.6% in the 65-69 age group, and then rose again. Most of the patients (78.7%) had invasive ductal, 7.8% were invasive lobular cancers, 9.8% were invasive mixed cancers (invasive ductal + invasive lobular), and 4% were other histological types (e.g. inflammatory, intracystic papillary, mucinous, etc.), respectively. Half of them (50%) had grade III histology. According to an analysis of pathological stages of all breast cancers (stage 0 - IV), 5% were stage 0, 27% were stage I, 44% were stage II, 21% were stage III, and 3% were stage IV breast cancer, respectively. The mean tumor diameter was 2.5 cm (±1.6; range 0.1-20 cm). The rates of lymphatic stages were pN0 50%, pN1 28%, pN2 15%, and pN3 7%, respectively. ER, PR, and HER-2 receptors were positive in 70%, 59%, and 23% of patients. A subtype analysis of tumors showed that 62% were type luminal A. This was followed by subtypes luminal B (15%), triple negative (15%), and HER-2 positive (8.5%). CONCLUSION As a conclusion patients with breast cancer in our breast cancer registry program were younger, and had more advanced disease, and worse prognostic factors than patients in developed countries.
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Affiliation(s)
- Vahit Özmen
- Department of General Surgery, İstanbul University İstanbul Medical Faculty, İstanbul, Turkey
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Pilewskie M, Morrow M. The Effect of Margin Width on Local Recurrence of Triple Negative Breast Cancer. CURRENT BREAST CANCER REPORTS 2014. [DOI: 10.1007/s12609-013-0132-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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17
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Hadzikadic Gusic L, McGuire K, Ozmen T, Soran A, Thomas C, McAuliffe P, Diego E, Bonaventura M, Johnson R, Ahrendt G. Margin width is not predictive of residual disease on re-excision in breast conserving therapy. J Surg Oncol 2013; 109:426-30. [DOI: 10.1002/jso.23530] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 11/07/2013] [Indexed: 11/06/2022]
Affiliation(s)
- L. Hadzikadic Gusic
- Division of Surgical Oncology, Department of Surgery, Levine Cancer Institute; Carolinas Medical Center; Charlotte North Carolina
| | - K.P. McGuire
- Division of Surgical Oncology, Section of Breast Surgery, Department of Surgery, Magee Women's Hospital; University of Pittsburgh; Pittsburgh Pennsylvania
| | - T. Ozmen
- Division of Surgical Oncology, Section of Breast Surgery, Department of Surgery, Magee Women's Hospital; University of Pittsburgh; Pittsburgh Pennsylvania
| | - A. Soran
- Division of Surgical Oncology, Section of Breast Surgery, Department of Surgery, Magee Women's Hospital; University of Pittsburgh; Pittsburgh Pennsylvania
| | - C.R. Thomas
- Division of Surgical Oncology, Section of Breast Surgery, Department of Surgery, Magee Women's Hospital; University of Pittsburgh; Pittsburgh Pennsylvania
| | - P.F. McAuliffe
- Division of Surgical Oncology, Section of Breast Surgery, Department of Surgery, Magee Women's Hospital; University of Pittsburgh; Pittsburgh Pennsylvania
| | - E.J. Diego
- Division of Surgical Oncology, Section of Breast Surgery, Department of Surgery, Magee Women's Hospital; University of Pittsburgh; Pittsburgh Pennsylvania
| | - M. Bonaventura
- Division of Surgical Oncology, Section of Breast Surgery, Department of Surgery, Magee Women's Hospital; University of Pittsburgh; Pittsburgh Pennsylvania
| | - R.R. Johnson
- Division of Surgical Oncology, Section of Breast Surgery, Department of Surgery, Magee Women's Hospital; University of Pittsburgh; Pittsburgh Pennsylvania
| | - G.M. Ahrendt
- Division of Surgical Oncology, Section of Breast Surgery, Department of Surgery, Magee Women's Hospital; University of Pittsburgh; Pittsburgh Pennsylvania
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Moser EC, Vrieling C. Accelerated partial breast irradiation: the need for well-defined patient selection criteria, improved volume definitions, close follow-up and discussion of salvage treatment. Breast 2012; 21:707-15. [PMID: 23127279 DOI: 10.1016/j.breast.2012.09.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2012] [Revised: 08/17/2012] [Accepted: 09/23/2012] [Indexed: 12/24/2022] Open
Abstract
Breast-conserving therapy, including whole breast irradiation, has become a well-established alternative to mastectomy in early-stage breast cancer patients, with similar survival rates and better cosmetic outcome. However, many women are still treated with mastectomy, due to logistical issues related to the long course of radiotherapy (RT). To reduce mastectomy rates and/or omission of RT after breast-conserving surgery, shorter, hypofractionated RT treatments have been introduced. More recently, the necessity of routinely treating the entire breast in all patients has been questioned, leading to the development of partial breast radiotherapy. With accelerated partial breast irradiation (APBI) these two approaches have been combined: the tumor bed with a 1-2 cm margin is irradiated either intra-operatively (single fraction) or postoperatively over 5-15 days. Different techniques have been developed, including interstitial brachytherapy, intra-cavity brachytherapy, intra-operative radiotherapy and external beam radiotherapy. These techniques are being evaluated in several ongoing phase III studies. Since its introduction, APBI has been the subject of continuous debate. ASTRO and GEC-ESTRO have published guidelines for patient selection for APBI, and strongly recommend that APBI be carried out within ongoing clinical trials. Recently, the patient selection criteria for APBI have also been up for debate, following the publication of results from different groups that do/do not confirm a difference in recurrence risk among the ASTRO defined risk groups. This paper reviews the different APBI techniques, current recommendations for patient selection, available clinical data and ongoing clinical trials. A case report is included to illustrate the need for careful follow-up of patients treated with APBI.
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Affiliation(s)
- Elizabeth C Moser
- Breast Unit/Department of Radiotherapy, Champalimaud Cancer Centre, Lisbon, Portugal.
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