DCIS Margins and Breast Conservation: MD Anderson Cancer Center Multidisciplinary Practice Guidelines and Outcomes

Kuerer, Henry Mark; Smith, Benjamin D.; Chávez-MacGregor, Mariana; Albarracin, Constance T.; Barcenas, Carlos H.; Santiago, Lumarie; Edgerton, Mary E.; Rauch, Gaiane M.; Giordano, Sharon H.; Şahin, Ayşegül; Krishnamurthy, Savitri; Woodward, Wendy A.; Tripathy, Debasish; Yang, Wei Tse; Hunt, Kelly K.

doi:10.7150/jca.20871

Cited by 44 publications

(33 citation statements)

References 56 publications

(54 reference statements)

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“…For DCIS, there was no statistically significant difference in locoregional recurrence (LRR) for patients with margins <2 versus ≥2 mm who received radiotherapy (10-year LRR 4.8% vs 3.3%, respectively; P = 0.72) 20. One other large study evaluating the relationship between margin width and recurrence did not identify a significant association of recurrence with margin width of ≤2 mm compared with larger margins for patients receiving radiotherapy 21.…”

Section: Discussionmentioning

confidence: 95%

<p>Positive or close margins: reoperation rate and second conservative resection or total mastectomy?</p>

Houvenaeghel¹,

Lambaudie²,

Bannier³

et al. 2019

CMAR

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Introduction Reoperation after breast-conserving surgery (BCS) could be proposed for positive or close margins. Reoperation type, re-excision or mastectomy, depends on several factors in relation to patient’s and tumor’s characteristics. We have analyzed our breast cancer (BC) database in order to determine second and third attempts for BCS and mastectomy rates, as well as associated factors for type of surgery. Methods All patients with BCS between 1995 and 2017 were included. Patient’s characteristics, pathologic results, and treatments were analyzed. Reoperation rate, type of reoperation, second reoperation, and associated factors of reoperation, mastectomy, and third intervention were determined. Three periods were determined: P1–P3. Results We analyzed 10,761 patients: 1,161 with ductal carcinoma in situ (DCIS) and 9,600 with invasive BC. The reoperation rate was 41.4% for DCIS and 28.0% for invasive BC. Using multivariate analysis, we identified tumor size >20 mm as being a risk factor for reoperation, whereas age >50 years, P2–3, and some localization decreased reoperation rates. For invasive BC, age >40 years, triple-negative tumors, neoadjuvant chemotherapy, and noncentral tumors decreased reoperation rates and lobular tumor, multifocal tumors, lymphovascular invasion, DCIS component, and Her2-positive tumors increased reoperation rates. For patients requiring reoperation, re-excision was performed in 48.1% (1,523/3,168) and mastectomy was required after first re-excision in 13.46% (205/1,523). For DCIS, mastectomy rates were higher for grade 2 and tumor ≥20 mm. For invasive BC, mastectomy rates were higher for lobular, multifocal, ≥20 mm, Her2-positive tumors and diffuse positive margins and lower for age >50 years and during the last period. Even if interval time between surgery and adjuvant treatments was higher for patients with reoperation, survival rates were not different between patients with and without reoperation. Conclusion A decrease in reoperation and mastectomy rates had been reported with several associated factors. A third intervention with mastectomy was required in 13.5% of patients. This information should be done in case of reoperation.

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Section: Discussionmentioning

confidence: 95%

<p>Positive or close margins: reoperation rate and second conservative resection or total mastectomy?</p>

Houvenaeghel¹,

Lambaudie²,

Bannier³

et al. 2019

CMAR

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“…Of these, margin status is the only factor that can be controlled by the surgeon, and the primary aim, of surgery is just the prevention of local recurrence by achieving microscopic free margins of excision, as it is traditionally recommended in practice guidelines (18)(19)(20). For these reasons, patients with extensive/multiple foci margin involvement and/or evidence of residual malignant appearing calcifications on post-operative mammography should undergo re-excision, if cosmetically feasible, or mastectomy, especially when there is margin involvement after repeated re-excision (21).…”

Section: Discussionmentioning

confidence: 99%

No Ink on Ductal Carcinoma In Situ: A Single Centre Experience

et al. 2018

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Background/Aim: A retrospective analysis of 388 patients with pure ductal carcinoma in situ (DCIS) was performed in order to test the correlation of clearance margin of resection and other host-, tumor-and treatmentrelated factors with ipsilateral breast tumor recurrence (IBTR). Materials and Methods: The pathological analysis was performed according to a standardized protocol: positive margins had DCIS at the inked margin; close margins had tumor between 0.1 to 0.9 mm, or 1 to 1.9 mm, and negative margins were ≥2 mm. Results: At a median follow-up of 90 months there were 26 IBTR (10 invasive and 16 DCIS). Both in univariate and multivariate analysis a significant difference was observed in IBTR by comparing positive versus close/negative margins of excision (p=0.05) and the number of re-operations (p=0.000). Moreover, the actuarial IBTR rates were significantly different in patients with a positive compared to close/negative margins (log-rank test, p=0.042) while the stratification by the margin width (0.1-0.9 mm; 1.0-1.9 mm; ≥2 mm) was not significant (logrank test, p=0.243). Conclusion: The policy of "no ink on the tumor" can be translated from invasive to DCIS, because the actuarial IBTR rates were significantly different only in patients with a positive, compared to close/negative margins.

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“…In patients undergoing whole-breast radiotherapy, a close negative margin (0-1.9 mm) is not by itself an indication for re-excision, and other prognostic factors such as patient age, residual mammographic abnormalities, DCIS extent, and grade should be considered [53,82,86]. Indeed, there is recent evidence showing that in the context of adjuvant radiotherapy, the risk of recurrence in patients with 0-1 mm margins and those with ≥2 mm margins is similar [82,87].…”

Section: Negative Margins ≥2 MMmentioning

confidence: 99%

Ductal carcinoma in situ of the breast: an update for the pathologist in the era of individualized risk assessment and tailored therapies

Hanna

Parra‐Herran

et al. 2019

Modern Pathology

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Ductal carcinoma in situ (DCIS) is a neoplastic proliferation of mammary ductal epithelial cells confined to the ductallobular system, and a non-obligate precursor of invasive disease. While there has been a significant increase in the diagnosis of DCIS in recent years due to uptake of mammography screening, there has been little change in the rate of invasive recurrence, indicating that a large proportion of patients diagnosed with DCIS will never develop invasive disease. The main issue for clinicians is how to reliably predict the prognosis of DCIS in order to individualize patient treatment, especially as treatment ranges from surveillance only, breast-conserving surgery only, to breast-conserving surgery plus radiotherapy and/ or hormonal therapy, and mastectomy with or without radiotherapy. We conducted a semi-structured literature review to address the above issues relating to "pure" DCIS. Here we discuss the pathology of DCIS, risk factors for recurrence, biomarkers and molecular signatures, and disease management. Potential mechanisms of progression from DCIS to invasive cancer and problems faced by clinicians and pathologists in diagnosing and treating this disease are also discussed. Despite the tremendous research efforts to identify accurate risk stratification predictors of invasive recurrence and response to radiotherapy and endocrine therapy, to date there is no simple, well-validated marker or group of variables for risk estimation, particularly in the setting of adjuvant treatment after breast-conserving surgery. Thus, the standard of care to date remains breast-conserving surgery plus radiotherapy, with or without hormonal therapy. Emerging tools, such as pathologic or biologic markers, may soon change such practice. Our review also includes recent advances towards innovative treatment strategies, including targeted therapies, immune modulators, and vaccines.

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DCIS Margins and Breast Conservation: MD Anderson Cancer Center Multidisciplinary Practice Guidelines and Outcomes

Cited by 44 publications

References 56 publications

<p>Positive or close margins: reoperation rate and second conservative resection or total mastectomy?</p>

<p>Positive or close margins: reoperation rate and second conservative resection or total mastectomy?</p>

No Ink on Ductal Carcinoma In Situ: A Single Centre Experience

Ductal carcinoma in situ of the breast: an update for the pathologist in the era of individualized risk assessment and tailored therapies

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