Optimizing Surgical Margins in Breast Conservation

Abstract

Adequate surgical margins in breast-conserving surgery for breast cancer have traditionally been viewed as a predictor of local recurrence rates. There is still no consensus on what constitutes an adequate surgical margin, however it is clear that there is a trade-off between widely clear margins and acceptable cosmesis. Preoperative approaches to plan extent of resection with appropriate margins (in the setting of surgery first as well as after neoadjuvant chemotherapy,) include mammography, US, and MRI. Improvements have been made in preoperative lesion localization strategies for surgery, as well as intraoperative specimen assessment, in order to ensure complete removal of imaging findings and facilitate margin clearance. Intraoperative strategies to accurately assess tumor and cavity margins include cavity shave techniques, as well as novel technologies for margin probes. Ablative techniques, including radiofrequency ablation as well as intraoperative radiation, may be used to extend tumor-free margins without resecting additional tissue. Oncoplastic techniques allow for wider resections while maintaining cosmesis and have acceptable local recurrence rates, however often involve surgery on the contralateral breast. As systemic therapy for breast cancer continues to improve, it is unclear what the importance of surgical margins on local control rates will be in the future.

Should cavity shave margins be performed as a routine in breast conserving surgery? A review of randomised controlled trials

“…The re-excision rates were also much lower in the CSM group, but the result was not statistically significant with a P value of 0.264. The risk of local recurrence depends on the tumour biology, genetic composition, ER status-higher risk in ER-negative patients and the patients requiring neoadjuvant chemotherapy, and positive margins [8,10,12]. Positive margins can increase the possibility of recurrence of the loco-regional disease.…”

“…Negative margin does not mean a complete absence of residual unresected tumour in the treated breast, but it results in decreased tumour burden low enough to be treated with radiotherapy. Positive margins are associated with 2 to 3 times increased the risk of local recurrence [7][8][9][10][11].…”

“…Several RCT and retrospective studies have shown that taking additional tissue circumferentially around the cavity (cavity shave margin-CSM) reduces the rate of positive margins. CSM have also shown to be useful in identifying multifocal disease [1][2][3][4][5][6][7][8][9][10][11].…”

Breast Cancer Surgery

“…Wider excisions do not significantly reduce the risk of local relapse compared to a 2 mm margin, but positive margins of less than 1 mm double the risk of relapse of breast cancer (10).…”

Correlação da dor e qualidade de vida de mulheres pós-tratamento cirúrgico de câncer de mama

“…As técnicas cirúrgicas não conservadoras como a mastectomia radical, envolve a remoção de todo o tecido mamário, havendo a retirada dos músculos peitorais, maior e menor. Em contrapartida, a mastectomia radical modificada apresenta preservação de um ou dois músculos peitorais 3,4 . Comumente as abordagens conservadoras e não conservadoras são acompanhadas pela téc-nica cirúrgica de dissecção de linfáticos axilares, realizada para prevenir o risco de recorrência axilar, porém em consequência deste procedimento, pode ocorrer a obstrução da drenagem linfática do membro, originando linfedema ipsilateral a cirurgia 5 .…”