Factors influencing reoperation following breast‐conserving surgery

Philpott, Andrew; Wong, Joshua; Elder, Kenneth; Gorelik, Alexandra; Mann, G. Bruce; Skandarajah, Anita

doi:10.1111/ans.14467

Cited by 13 publications

(15 citation statements)

References 41 publications

(51 reference statements)

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“…In this study, preoperative factors associated with positive resection margins were mammographic tumour size, a diagnosis of ILC, microscopic calcifications or DCIS on core needle biopsy, and tumour distance from the NAC. These findings confirm previously published results showing that central tumours 11 , 25 , ILC 8 , 12 , 25–33 , DCIS 12 , 15 , 16 , 26 , 32 , tumour size 14–16 , 28 , 29 , 31 , 33 , and microscopic calcifications on mammography 15 , 16 are associated with suspected residual disease. In contrast, there was no association between positive margins and tumour palpability and clinical node positivity.…”

Section: Discussionsupporting

confidence: 92%

“…The present prediction model did not include radiographic variables other than mammographic tumour size, visibility of the tumour mass, and the presence of microcalcifications, whereas other studies 14 , 18 , 26 , 28 have included a variety of MRI features. The importance of MRI for predicting positive resection margins was inconclusive in larger studies 36 , 37 .…”

Section: Discussionmentioning

confidence: 99%

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Validated prediction model for positive resection margins in breast-conserving surgery based exclusively on preoperative data

et al. 2021

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Background Positive margins after breast-conserving surgery (BCS) and subsequent second surgery are associated with increased costs and patient discomfort. The aim of this study was to develop a prediction model for positive margins based on risk factors available before surgery. Methods Patients undergoing BCS for in situ or invasive cancer between 2015 and 2016 at site A formed a development cohort; those operated during 2017 in site A and B formed two validation cohorts. MRI was not used routinely. Preoperative radiographic and tumour characteristics and method of operation were collected from patient charts. Multivariable logistic regression was used to develop a prediction model for positive margins including variables with discriminatory capacity identified in a univariable model. The discrimination and calibration of the prediction model was assessed in the validation cohorts, and a nomogram developed. Results There were 432 patients in the development cohort, and 190 and 157 in site A and B validation cohorts respectively. Positive margins were identified in 77 patients (17.8 per cent) in the development cohort. A non-linear transformation of mammographic tumour size and six variables (visible on mammography, ductal carcinoma in situ , lobular invasive cancer, distance from nipple–areola complex, calcification, and type of surgery) were included in the final prediction model, which had an area under the curve of 0.80 (95 per cent c.i. 0.75 to 0.85). The discrimination and calibration of the prediction model was assessed in the validation cohorts, and a nomogram developed. Conclusion The prediction model showed good ability to predict positive margins after BCS and might, after further validation, be used before surgery in centres without the routine use of preoperative MRI. Presented in part to the San Antonio Breast Cancer Symposium, San Antonio, Texas, USA, December 2018 and the Swedish Surgical Society Annual Meeting, Helsingborg, Sweden, August 2018.

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Section: Discussionsupporting

confidence: 92%

Section: Discussionmentioning

confidence: 99%

Validated prediction model for positive resection margins in breast-conserving surgery based exclusively on preoperative data

et al. 2021

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“…When analysis of mastectomy rates was performed according to the three periods of treatment (DCIS and invasive), we observed a decrease in mastectomy rates among successive periods from 59.62% (2,739/4,594, 95% CI 58.2–61.0) to 48.8% (2,532/5,191, 95% CI 47.4–50.2) and 36.81% (6,892/17,903, 95% CI 36.1–37.5) 3,4,6,7,9,11. In the study reported by Wilke et al,5 the mastectomy rate was 37.9% for patients operated between 2004 and 2010.…”

Section: Discussionmentioning

confidence: 95%

“…Mastectomy rates were different according to histological types of tumor: 49.7% (1,960/3,942, 95% CI 48.1–51.3) for DCIS,1,4–6,8,11,13,14 50.9% (9,446/18,566, 95% CI 50.2–51.6) for invasive BC, 55.7% (95% CI 54.5–56.9) for ductal invasive BC, 70.5% (95% CI 68.3–72.7) for lobular invasive BC, and 60.9% (95% CI 57.8–64.0) for other invasive histological types 2…”

Section: Discussionmentioning

confidence: 99%

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<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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Changes in Reoperation After Publication of Consensus Guidelines on Margins for Breast-Conserving Surgery

et al. 2020

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The 2014 publication of the Society of Surgical Oncology-American Society for Radiation Oncology (SSO-ASTRO) Consensus Guideline on Margins for Breast-Conserving Surgery recommended a negative margin definition of no ink on tumor. Adoption of this guideline would represent a major change in surgical practice that could lower the rates of reoperation.OBJECTIVE To assess changes in reoperation rates after publication of the SSO-ASTRO guideline.DATA SOURCES A systematic search of Embase, PREMEDLINE, Evidence-Based Medicine Reviews, Scopus, and Web of Science for biomedical literature published from January 2014 to July 2019 was performed. This search was supplemented by web searches and manual searching of conference abstracts.STUDY SELECTION Included studies compared the reoperation rates in preguideline vs postguideline cohorts (actual change), retrospectively applied the SSO-ASTRO guideline to a preguideline cohort (projected change), or described the economic outcomes of the guideline.DATA EXTRACTION AND SYNTHESIS Study characteristics and reoperation rates were extracted independently by 2 reviewers. Odds ratios (ORs) were pooled by random effects meta-analysis. Analyses were stratified by study setting (institutional or population) and preguideline accepted margins. The economic outcomes of the guideline were summarized narratively. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was followed. MAIN OUTCOMES AND MEASURESOdds ratios for postguideline vs preguideline reoperation rates.RESULTS From 1114 citations, 30 studies (with 599 016 participants) reported changes in reoperation rates. Studies included a median (range) of 487 (100-521 578) participants, and 20 studies were undertaken in the US, 6 in the UK, 3 in Canada, and 1 in Australia. Among 21 studies of actual changes, pooled ORs showed a statistically significant reduction in reoperation, with an OR lower in institution-based studies than in population-based studies (OR, 0.62 [95% CI, 0.52-0.74] vs 0.76 [95% CI, 0.72-0.80]; P = .04 for subgroup differences). Among 9 studies of projected changes, the pooled OR was lower for preguideline margin thresholds of 2 mm or more compared with 1 mm (OR, 0.47 [95% CI, 0.40-0.56] vs 0.85 [95% CI, 0.79-0.91; P < .001 for subgroup differences). Projected changes were likely to overestimate actual changes. Six studies that estimated the postguideline economic outcome found the guideline to be potentially cost saving, with a median (range) saving of US $3540 ($1800-$25 650) per woman avoiding reoperation.CONCLUSIONS AND RELEVANCE This study found a decrease in reoperation rates after the publication of the SSO-ASTRO guideline; this reduction was greater at an institutional level than a population level, the latter reflecting the differences in guideline adoption between centers. These early outcomes may be conservative estimates of longer-term implications.

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Factors influencing reoperation following breast‐conserving surgery

Cited by 13 publications

References 41 publications

Validated prediction model for positive resection margins in breast-conserving surgery based exclusively on preoperative data

Validated prediction model for positive resection margins in breast-conserving surgery based exclusively on preoperative data

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

Changes in Reoperation After Publication of Consensus Guidelines on Margins for Breast-Conserving Surgery

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