Involved margins after lumpectomy for breast cancer: Always to be re-excised?

Abstract

Background: The oncologic benefit of upfront re-excision of involved margins after breastconserving surgery in the context of current multimodal clinical management of breast cancer is unclear. The aim of the present study was to assess the 5-years locoregional recurrence (LRR)-free and distant metastases (DM)-free survival probabilities in patients not undergoing re-excision of positive margins after lumpectomy for breast cancer. Methods: A cohort of 104 patients with positive margins not undergoing re-excision was matched by propensity score with a cohort of 2,006 control patients with clear margins after breastconserving surgery, treated between 2008 and 2018. A multivariate survival analysis was performed accounting for all variables related to LRR and DM, including adjuvant treatments. Results: After adjusting for potential confounders, avoiding to re-excise a positive margin after lumpectomy had no effect on 5-years LRR-free survival probability (HR 0.98, 95%CI 0.36-2.67, p=0.96) or 5-years DM-free survival probability (HR 0.37, 95%CI 0.08-1.61, p=0.18). No correlation was found between occurrence of LRR and number of involved margins (HR 1.28, 95%CI 0.10-12.4, Log-rank p=0.83), or extension of infiltrating disease (HR 1.21, 95%CI 0.20-7.40, Log-rank p=0.83), but a trend toward higher LRR probability was found for invasive ductal (HR 6.92, 95%CI 0.7-68.8, Log-rank p=0.10) and invasive lobular cancer (HR 12.95, 95%CI 0.79-213.6, Log-rank p=0.07) on positive margins. Conclusions: In the era of multimodal treatment of breast cancer and accurate strategies to reduce the probability of residual disease in the post-lumpectomy cavity, re-excision of positive margins might be omitted in selected patients with low-risk breast cancers.

Occurrence of residual disease in specimens of re‐excision surgery in patients with positive margins of primary quadrantectomy

“…The rate of residual disease in our study falls in the lower limit of previous reports having a rate between 28.2% and 62.7%. 16,19,22,27,28 no difference regarding the loco-regional recurrence and metastasis rates between control patients with clear margins after the first surgery and the patients who refused a secondary surgery despite having positive margins. 22 Vos et al found that the combination of omitting re-excision and addition of a whole-breast irradiation do not lower disease-free survival and overall survival in patients with focally positive margins from the primary lumpectomy, although omitting re-excision can increase the rates of ipsilateral tumor recurrence.…”

“…16,19,22,27,28 no difference regarding the loco-regional recurrence and metastasis rates between control patients with clear margins after the first surgery and the patients who refused a secondary surgery despite having positive margins. 22 Vos et al found that the combination of omitting re-excision and addition of a whole-breast irradiation do not lower disease-free survival and overall survival in patients with focally positive margins from the primary lumpectomy, although omitting re-excision can increase the rates of ipsilateral tumor recurrence. 24 In another study by Fisher et al, they described that breast cancer-related death was not influenced by re-excision compared to the group with no further re-excision after quadrantectomy.…”

“…The results demonstrated a relatively low rate of positive margins (2.4%) but still in accordance with similar studies having a positive margin ranging from 1.2 to 32%. 16,[19][20][21][22][23][24][25][26] According to our institutional strategy, intraoperative frozen section analysis is performed in operating rooms in patients undergoing quadrantectomy and extending the surgical margins is done in cases with involved margins to obtain a negative margin and this can explain our significant low rates of positive margins in permanent pathology report in our institution. Similar to our strategy, in a study by Racz et al, frozen margin assessment was done intraoperatively in case of compromised margins to minimize the rate of positive margin in permanent pathology report and hence the need for re-excision surgery.…”

Does Breast Cancer Subtype Impact Margin Status in Patients Undergoing Partial Mastectomy?

“…12 Some studies estimate that 20% to 50% of patients return to the operating room for positive or inadequate margins. 13,14 The economic cost is significant with one group demonstrating that return to the operating room for re-excision will result in nearly an 85% increase in cost per patient. 15 Even more importantly, inadequate surgical resection results in emotional and psychological strain for the individual patients.…”

Residual Risk of Ipsilateral Tumor Recurrence in Patients Who Achieved Clear Lumpectomy Margins After Repeated Resection

“…While studies have demonstrated that re-excision for breast conservation does not influence the overall survival of patients [ 23 24 ], the oncologic benefit of re-excision for positive resection margins remains unclear. Based on a propensity score matching analysis of 2,110 patients, Sorrentino et al [ 25 ] reported no significant benefit in local control with re-excision. However, this finding differs from that of Vos et al [ 24 ], who reported a significantly high risk of IBTR with the omission of re-excision in patients with positive margins.…”