Focally positive margins in breast conserving surgery: Predictors, residual disease, and local recurrence

Introduction Although close radial margins after breast-conserving surgery routinely undergo re-excision, appropriate management of patients with close anterior margins remains a topic of controversy. An increasing body of literature suggests that re-excision of close anterior margins yields low rates of residual malignancy and may only be necessary in selected patients. The aim of this study was to examine the management of close anterior margins after breast conserving surgery in a single institution and to analyse the rate of residual disease in re-excised anterior margins. Methods All patients having breast conserving surgery at St Vincent’s University Hospital from January 2008 to December 2012 were reviewed retrospectively. Data collected included patient demographics, tumour characteristics, margin positivity, re-excision rates and definitive histology of the re-excision specimens. A close margin was defined as les than 2 mm. Results A total of 930 patients were included with an average age of 65 years (range 29–94 years). Of these, 121 (13%) had a close anterior margin. Further re-excison of the anterior margin was carried out in 37 patients (30.6%) and a further 16 (13.2%) proceeded to mastectomy. Residual disease was found in 18.5% (7/36) of those who underwent re-excision and 7/16 (43.75%) of those who underwent mastectomy. Overall, 11.57% (14/121) of patients with close anterior margins were subsequently found to have residual disease. Conclusion The low yield of residual disease in re-excised anterior margins specimens supports the concept that routine re-excision of close anterior margins is not necessary. Further research is required to definitively assess its influence on the risk of local recurrence.

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Subsets of women with close or positive margins after breast-conserving surgery with high local recurrence risk despite breast plus boost radiotherapy

Breast Diseases A Year Book Quarterly ◽

10.1016/j.breastdis.2012.03.022 ◽

2012 ◽

Vol 23 (2) ◽

pp. 166-169

Author(s):

A. Recht

Keyword(s):

Local Recurrence ◽

Recurrence Risk ◽

Breast Conserving Surgery ◽

Positive Margins ◽

Boost Radiotherapy

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Outcome at 8 Years After Breast-Conserving Surgery and Radiation Therapy for Invasive Breast Cancer: Influence of Margin Status and Systemic Therapy on Local Recurrence

Journal of Clinical Oncology ◽

10.1200/jco.2000.18.8.1668 ◽

2000 ◽

Vol 18 (8) ◽

pp. 1668-1675 ◽

Cited By ~ 404

Author(s):

Catherine C. Park ◽

Michihide Mitsumori ◽

Asa Nixon ◽

Abram Recht ◽

James Connolly ◽

...

Keyword(s):

Breast Cancer ◽

Logistic Regression ◽

Radiation Therapy ◽

Local Recurrence ◽

Systemic Therapy ◽

Surgical Margin ◽

Breast Conserving Surgery ◽

Margin Status ◽

Positive Margins

PURPOSE: To examine the relationship between pathologic margin status and outcome at 8 years after breast-conserving surgery and radiation therapy. PATIENTS AND METHODS: The study population comprised 533 patients with International Union Against Cancer/American Joint Committee on Cancer clinical stage I or II breast cancer who had assessable margins, who received at least 60 Gy to the primary tumor bed, and who had more than 8 years of potential follow-up. Each margin was scored (according to the presence of invasive or in situ disease that touched the inked surgical margin) as one of the following: negative, close, focally positive, or extensively positive. Outcome at 8 years was calculated using crude rates of first site of failure. A polychotomous logistic regression analysis was performed. Median follow-up time was 127 months. RESULTS: At 8 years, patients with close margins and those with negative margins both had a rate of local recurrence (LR) of 7%. Patients with extensively positive margins had an LR rate of 27%, whereas patients with focally positive margins had an intermediate rate of LR of 14%. In the polychotomous logistic regression model, margin status and the use of systemic therapy were the only two variables that had significant effects on the risk ratio of LR to remaining alive and free of disease. Among the 45 patients with focally positive margins who received systemic therapy, the crude LR rate was 7% at 8 years (95% confidence interval, 1% to 20%). CONCLUSION: Pathologic margin status and the use of adjuvant systemic therapy are the most important factors associated with LR among patients treated with breast-conserving surgery and radiation therapy.

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Higher Volume at Time of Breast Conserving Surgery Reduces Re-Excision in DCIS

International Journal of Surgical Oncology ◽

10.1155/2011/785803 ◽

2011 ◽

Vol 2011 ◽

pp. 1-10 ◽

Cited By ~ 2

Author(s):

J. H. Wolf ◽

Y. Wen ◽

D. Axelrod ◽

D. Roses ◽

A. Guth ◽

...

Keyword(s):

Surgical Technique ◽

Residual Disease ◽

Breast Conserving Surgery ◽

Breast Conserving Therapy ◽

Positive Margins ◽

Impact Rate ◽

Lower Volume ◽

Pathologic Assessment ◽

Er Status

Purpose. The purpose of this study was to compare the surgical and pathological variables which impact rate of re-excision following breast conserving therapy (BCS) with or without concurrent additional margin excision (AM).Methods. The pathology database was queried for all patients with DCIS from January 2004 to September 2008. Pathologic assessment included volume of excision, subtype, size, distance from margin, grade, necrosis, multifocality, calcifications, and ER/PR status.Results. 405 cases were identified and 201 underwent BCS, 151-BCS-AM, and 53-mastectomy. Among the 201 BCS patients, 190 underwent re-excision for close or involved margins. 129 of these were treated with BCS and 61 with BCS-AM (P<.0001). The incidence of residual DCIS in the re-excision specimens was 32% (n=65) for BCS and 22% (n=33) for BCS-AM (P<.05). For both the BCS and the BCS-AM cohorts, volume of tissue excised is inversely correlated to the rate of re-excision (P=.0284). Multifocality (P=.0002) and ER status (P=.0382) were also significant predictors for rate of re-excision and variation in surgical technique was insignificant.Conclusions.The rate of positive margins, re-excision, and residual disease was significantly higher in patients with lower volume of excision. The performance of concurrent additional margin excision increases the efficacy of BCS for DCIS.

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Subsets of women with close or positive margins after breast-conserving surgery with high local recurrence risk despite breast plus boost radiotherapy

Yearbook of Oncology ◽

10.1016/s1040-1741(12)00204-7 ◽

2012 ◽

Vol 2012 ◽

pp. 61-65

Author(s):

A. Recht

Keyword(s):

Local Recurrence ◽

Recurrence Risk ◽

Breast Conserving Surgery ◽

Positive Margins ◽

Boost Radiotherapy

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The impact of pattern of tumor response and other post-treatment histologic features on local recurrence in patients treated with neoadjuvant chemotherapy and breast conservation.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.15_suppl.581 ◽

2020 ◽

Vol 38 (15_suppl) ◽

pp. 581-581

Author(s):

Alison Laws ◽

Ricardo G. Pastorello ◽

Jungeon Choi ◽

Olga Kantor ◽

Samantha Grossmith ◽

...

Keyword(s):

Local Recurrence ◽

Neoadjuvant Chemotherapy ◽

Treatment Effect ◽

Tumor Response ◽

Residual Disease ◽

Breast Conserving Surgery ◽

Invasive Disease ◽

Post Treatment ◽

The Impact

581 Background: Residual disease after neoadjuvant chemotherapy (NAC) is a poor prognostic factor. The relationship between the pattern of tumor response and other post-treatment histologic features on local recurrence (LR) is not well studied. Methods: We identified 380 patients (pts) treated with NAC, breast-conserving surgery and radiation from 2002-2014. Pts with available surgical slides underwent detailed pathology review. Pathologic complete response (pCR) was defined as no invasive or in situ disease in the breast or axilla. Pattern of tumor response was defined as: none, scattered, or concentric. The degree of treatment effect was categorized as: absent, mild or marked. Univariate (UVA) and multivariate analyses (MVA) were performed to identify factors associated with LR. Results: 243 (64%) cases had complete slides available and formed the study cohort. 76 (31%) were ER+/HER2-, 90 (38%) ER-/HER2- and 77 (31%) HER2+. 98% of HER2+ pts received neoadjuvant trastuzumab; 89% of ER+ pts received adjuvant endocrine therapy. At median follow-up of 75 months, 10/243 (4.1%) pts had LR and 5-yr LR-free survival was 95.7%. LR occurred in 1/76 (1.3%) pts with breast pCR, 1/19 (5.2%) with residual DCIS, and 8/148 (5.4%) with residual invasive disease; including 6/78 (7.7%) with scattered tumor response, 2/46 (4.3%) with concentric response and 0/24 with no response. On UVA, age (OR < 50 vs ≥50 5.9, p = 0.03) and residual DCIS with comedonecrosis (OR 8.2, p < 0.01) were significantly associated with LR. Presence of tumor bed at the margin (OR 4.6, p = 0.06) approached significance. The odds of LR were higher with scattered regression (OR 1.83 vs. concentric, p = 0.47) and lower with breast pCR (OR 0.23, p = 0.17), but these results were not statistically significant. Multicentric disease, receptor status, ypT, ypN, RCB score, degree of treatment effect, high-grade residual invasive disease, margin status of residual disease and lymphovascular invasion were not associated with LR (all p > 0.05). Age (OR < 50 vs ≥50 7.4, p = 0.04) and residual DCIS with comedonecrosis (OR 7.5, p = 0.02) remained significant on MVA. Conclusions: With modern systemic therapy, LR rates after NAC, breast-conserving surgery and radiation are low, with less than 5% of patients experiencing a LR after a median follow-up of over 6 years. Young age and residual DCIS with comedonecrosis were associated with LR, but not pattern of tumor response.

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