Role of resection margins in patients treated with breast conservation surgery

Abstract

BACKGROUND After breast conservation therapy (BCT), margin status is routinely evaluated to select patients who need reexcision. The aim of this study was to investigate how margin status and other clinicopathologic factors correlate with the presence of residual tumor at reexcision. METHODS A series of 431 breast cancer patients who underwent BCT followed by reexcision were considered because they had positive or close (≤3 mm) margins. At univariate and multivariate analysis the frequency of residual tumor in the reexcision specimens was associated with the status and width of resection margins and with a series of other clinicopathologic factors. RESULTS Of the 382 evaluable patients, 253 had positive and 129 close margins. Residual tumor was found at reexcision in 51.8% positive‐margin patients and 34.1% close‐margin patients (P = .001). In the latter group tumor‐margin distance (range, 0.08 to 3 mm) was not associated with the incidence of residual tumor (P = .134). On univariate analysis age ≤45 years (P = .006), intraductal histotype (P = .005), size > 2 cm (P = .010), positive axillary nodes (P = .031), and timing of reexcision (P = .044) were significantly associated with a higher frequency of residual tumor. All these factors, except tumor size, maintained a significant predictive value on multivariate analysis. CONCLUSIONS In the presence of positive margins, relevant residual disease cannot be ruled out and further surgery is indicated. Close margins do not mandate reexcision because they may indicate either that the tumor has been radically excised or the presence of residual foci of a multifocal tumor, which are usually effectively treated by radiotherapy. Cancer 2008. © 2008 American Cancer Society.

Variation between hospitals in surgical margins after first breast-conserving surgery in the Netherlands

“…The criteria determining the indication for re-excision differ between DCIS and invasive cancer. For invasive cancer, the clinical importance of re-excising tumors with only focally involved margins in invasive breast cancer is [11,[13][14][15][16][17]. The Dutch treatment guideline (2008) advises only re-excision in patients with 'more than focally positive' margins.…”

Multicentre randomised controlled trial examining the cost-effectiveness of contrast-enhanced high field magnetic resonance imaging in women with primary breast cancer scheduled for wide local excision (COMICE)

“…Details of repeat MRI findings are displayed in Appendix 15 (Clinical significance of < 5-mm MRI-only-detected lesions: repeat MRI findings) for those patients who underwent a repeat scan. Median time from randomisation to repeat MR scan was 15 months (range [8][9][10][11][12][13][14][15][16][17][18][19]. Median time from starting adjuvant radiotherapy to repeat scan was 13 months (range 4-17) for the 12 patients who received radiotherapy.…”

“…As radiotherapy reduces the ipsilateral breast tumour recurrence rate by a factor of four, resulting in a 75% local control rate, the concept of 'close' margins, with tumour extending to within 1-2 mm of the edge of the specimen, has gained increasing acceptance. [9][10][11][12] However, it is likely that the residual tumour burden decreases with increasing margin width, and, as a consequence, the margin width deemed acceptable varies between centres and will drive the need for further local treatments.…”

Surgical margins in breast cancer management

“…Zavagno et al [60] ont analysé 431 cancers du sein ; 253 avaient des marges positives, 129 avaient des marges inferieures ou é gales à 3 mm. Lors de la reprise chirurgicale de ces cancers, dans le groupe de cancer avec marges envahies, il é tait retrouvé un ré sidu tumoral dans 51,8 % des cas ; dans le groupe avec des marges inferieures ou é gales à 3 mm, 65,9 % n'avait pas de ré sidu tumoral (p = 0,01).…”

“…Par contre, la pré sence de marges positives aprè s la chirurgie est associé e à un risque plus important de ré cidive locale malgré des traitements adjuvants, avec des ré cidives locales plus tardives [60]. De plus, la reprise chirurgicale pour des marges insuffisantes permettrait d'obtenir des taux de ré cidive locale de l'ordre de ceux de marges né gatives d'emblé e : dans l'é tude de Anscher et al, les patients ayant eu une reprise du lit tumoral avec obtention de marges né gatives avaient un taux de rechute locale similaire à ceux avec marges saines d'emblé e, soit 2 et 1,5 % à cinq ans respectivement ; par contre, il é tait de 28 % pour les patients ayant des marges positives aprè s reprise [1].…”