Close or Positive Margins After Mastectomy for DCIS: Pattern of Relapse and Potential Indications for Radiotherapy

Rashtian, Afshin; Iganej, S.; Liu, In‐Lu Amy; Natarajan, Shyam

doi:10.1016/j.ijrobp.2008.06.1954

Cited by 65 publications

(63 citation statements)

References 16 publications

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“…Few patients are considered to have sufficiently high risk to justify PMRT, but based on clinical parameters such as extent of disease, high grade, positive margins, or young age, radiation may occasionally be given. This recommendation is supported by two studies, which reported long-term recurrence rates of 16% and 11% for mastectomy margins of less than or equal to 2 mm (11,17). In contrast, we have found an 8-year locoregional recurrence rate below 2% in women with close or positive margins after mastectomy without radiation (18).…”

supporting

confidence: 74%

“…A small review of 10 chest wall recurrences in this setting has suggested that young age and multifocality are associated with increased risk of locoregional failure (25). One recent study reported a series of 80 patients who had undergone mastectomy for DCIS and had margins <10 mm (17). At a median follow-up of 61 months, six patients (7.5%) had a local recurrence.…”

mentioning

confidence: 99%

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The Impact of Surgery on Ductal Carcinoma In Situ Outcomes: The Use of Mastectomy

Hwang

2010

JNCI Monographs

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Genomic and phenotypic similarities between ductal carcinoma in situ (DCIS) and invasive breast cancer support that DCIS is likely a nonobligate precursor of invasive ductal cancer. Because it remains difficult to predict which individuals with DCIS will develop invasive cancer without excision, surgery has long been the mainstay of treatment for women diagnosed with DCIS. Presently in the United States, 97% of patients with DCIS undergo surgical excision, of which one-third will involve mastectomy (1,2). The most recent NCCN Clinical Practice Guidelines in Oncology (v.2.2010) recommend total mastectomy as one treatment option for DCIS (3). General guidelines for the use of mastectomy in DCIS have been suggested by an expert panel convened by the American College of Radiology (4) and recommend that patients with extensive and/or multifocal DCIS involving 4-5 cm of disease or more than one quadrant should be offered mastectomy. In addition to these patients, women with potential contraindications to breast irradiation or a strong preference for mastectomy over breast conservation have been considered appropriate candidates for this procedure.In the United States, the use of mastectomy for treatment of DCIS has declined steadily. Among the cancer registries participating in the Surveillance, Epidemiology, and End Results (SEER) Program, 43% of women with DCIS underwent mastectomy in 1992 compared with 28% in 1999 (1). However, significant variations in surgical treatment patterns for DCIS persist among SEER sites: between 1997 and 2000, those treated with mastectomy for DCIS ranged from the highest rate of 50.5% in Utah to the lowest rate of 23.1% in Connecticut (5). Factors reported to be associated with a higher likelihood of mastectomy for DCIS have included young age at diagnosis, geographic site, and white race (5,6). Following treatment for DCIS, the risk of contralateral breast events has been shown to be 4.5/1000 personyears (7). Despite this increased contralateral breast cancer risk, few women have previously undergone contralateral prophylactic surgery for DCIS. However, there has been a recent surge in the prevalence of contralateral prophylactic mastectomy (CPM), and between 1998 to 2005, the CPM rate in women with DCIS increased from 2.1% to 5.2% (8). Factors contributing to this increase most certainly include the inaccurate perception many women with DCIS harbor regarding their future risk for invasive cancer (9), although improved reconstructive outcomes and more widespread use of magnetic resonance imaging have also been proposed as contributing causes.Various surgical approaches for mastectomy are currently used and include simple mastectomy (excision of breast tissue and overlying skin), skin-sparing mastectomy (removal of breast with preservation of the skin envelope), and most recently, nipple-preserving mastectomy techniques. None of these approaches appear to confer increased risk of local recurrence over the others, provided that conscientious attention is given to performing a complete ex...

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confidence: 74%

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confidence: 99%

The Impact of Surgery on Ductal Carcinoma In Situ Outcomes: The Use of Mastectomy

Hwang

2010

JNCI Monographs

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“…This high LRR rate among patients with margins \2 mm has led some practitioners to consider PMRT when margins are \2 mm or positive. 18 Chadha et al studied 207 patients treated with mastectomy for DCIS and reported that LRR occurred in two patients (0.9 %). Both LRRs occurred in patients with margins \1 mm, and there were no LRRs among patients with margins C1 mm.…”

Section: Discussionmentioning

confidence: 99%

Incidence and Consequence of Close Margins in Patients with Ductal Carcinoma-In Situ Treated with Mastectomy: Is Further Therapy Warranted?

Sarma¹,

Hwang²

2014

Breast Diseases: A Year Book Quarterly

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“…At present, young age per se should not be a contraindication for BCT, especially because it is unknown whether these patients have a superior long-term prognosis if treated by mastectomy. Local recurrences followingboth skin sparing and simple-mastectomy after DCIS are reported and also seem to occur particularly in younger women (12,13).Numerous studies have shown an increased risk of local recurrence when DCIS was excised with doubtful or involved margins (2,6,7,14,15). Various thresholds have been reported as a safe margin status, from "the inked margin not being involved with DCIS," to ≥1, 2, 3, or 5 mm, or even ≥1 cm.…”

mentioning

confidence: 99%

mentioning

confidence: 99%

Local and Systemic Outcomes in DCIS Based on Tumor and Patient Characteristics: The Radiation Oncologist's Perspective

Bijker

Tienhoven

2010

JNCI Monographs

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Four randomized controlled trials have shown the benefit of radiotherapy after breast-conserving surgery for ductal carcinoma in situ (DCIS) (1-4). Radiotherapy reduces the risk of both DCIS and invasive local recurrence with about 50%, with a similar relative reduction of the recurrence risk in all clinical and pathological subgroups analyzed (5). Age and margin status are the most important factors related to the risk of local recurrence. The impact of young age on the outcome of treatment of DCIS has been studied by several groups (2,6-9). In the EORTC 10853 trial, women aged 40 years or younger had a 34% risk of local recurrence at 10 years compared with 19% of the women older than 40 years ( Figure 1). Potential factors responsible for the increased risk of local recurrence after breast-conserving therapy (BCT) for DCIS in young women are adverse prognostic pathological features that appear to occur more frequently in young women and treatment-related factors such as a smaller excision volume (10). However, to date, data are limited and sometimes inconsistent (10). In the EORTC trial, young women had a higher rate of clinically detected lesions than older women (63% vs 24%) (11). Younger women had a similar rate of excisions without free margins (11). At present, young age per se should not be a contraindication for BCT, especially because it is unknown whether these patients have a superior long-term prognosis if treated by mastectomy. Local recurrences followingboth skin sparing and simple-mastectomy after DCIS are reported and also seem to occur particularly in younger women (12,13).Numerous studies have shown an increased risk of local recurrence when DCIS was excised with doubtful or involved margins (2,6,7,14,15). Various thresholds have been reported as a safe margin status, from "the inked margin not being involved with DCIS," to ≥1, 2, 3, or 5 mm, or even ≥1 cm. Single institutional studies have suggested that radiotherapy can safely be omitted when margins are ≥1 cm (16); however, prospective studies have not confirmed this (17). In the EORTC trial, when margins were not reported free, the local recurrence rate at 10 years was overall 32% (Figure 2), with 39% in the local excision group and 24% in the excision plus radiotherapy group. To conclude, when margins are involved, the risk of recurrence is high, even after radiotherapy. Yet, it remains unknown which is an optimal minimal margin for BCT.Involved margins after lumpectomy for DCIS are an indication for further surgery. If, after excision and/or re-excision, no clear margins can be obtained, a mastectomy will be indicated. Particularly in larger lesions, the chance of performing a microscopically complete local excision is considered low. In practice, 25%-30% of women with DCIS are treated with mastectomy (18). The extent of the DCIS and inability to obtain clear margins with breast-conserving surgery are likely to be responsible for this percentage.In all randomized trials, the dose delivered was 50 Gy without an additional dose to the tumo...

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Close or Positive Margins After Mastectomy for DCIS: Pattern of Relapse and Potential Indications for Radiotherapy

Cited by 65 publications

References 16 publications

The Impact of Surgery on Ductal Carcinoma In Situ Outcomes: The Use of Mastectomy

The Impact of Surgery on Ductal Carcinoma In Situ Outcomes: The Use of Mastectomy

Incidence and Consequence of Close Margins in Patients with Ductal Carcinoma-In Situ Treated with Mastectomy: Is Further Therapy Warranted?

Local and Systemic Outcomes in DCIS Based on Tumor and Patient Characteristics: The Radiation Oncologist's Perspective

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