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Fox SB, Webster F, Chen CJ, Chua B, Collins LC, Foschini MP, Mann GB, Millar EKA, Pinder SE, Rakha E, Shaaban AM, Tan BY, Tse GM, Watson PH, Tan PH. Dataset for pathology reporting of ductal carcinoma in situ, variants of lobular carcinoma in situ and low grade lesions: recommendations from the International Collaboration on Cancer Reporting (ICCR). Histopathology 2022; 81:467-476. [DOI: 10.1111/his.14725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/05/2022] [Accepted: 07/05/2022] [Indexed: 11/28/2022]
Affiliation(s)
- SB Fox
- Department of Pathology, Peter MacCallum Cancer Centre, Level 4 Victorian Comprehensive Cancer Centre Melbourne VIC 3000 Australia
| | - F Webster
- International Collaboration on Cancer Reporting, Albion St, Surry Hills NSW 2010 Australia
| | - CJ Chen
- Department of Pathology and Laboratory Medicine, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4 Taichung 40705 Taiwan
| | - B Chua
- Prince of Wales Clinical School, UNSW Sydney The University of New South Wales Randwick NSW 2031 Australia
| | - LC Collins
- Department of Pathology, Beth Israel Deaconess Medical Center, 330 Brookline Ave and Harvard Medical School Boston MA 02215 USA
| | - MP Foschini
- Department Anatomic Pathology University of Bologna Department of Biomedical and Neuromotor Sciences Unit of Anatomic Pathology at Bellaria Hospital, Via Altura 3 40139 Bologna Italy
| | - GB Mann
- The Breast Service, The Royal Melbourne Hospital, Grattan St Parkville VIC 3050 Australia
| | - EKA Millar
- Department of Anatomical Pathology Heath Pathology St George Hospital, Kogarah NSW 2217 & St George & Sutherland Clinical School, UNSW NSW Sydney Australia
| | - SE Pinder
- School of Cancer & Pharmaceutical Sciences King's College London, 9th Floor, Innovation Hub, Comprehensive Cancer Centre at Guy's Hospital, Great Maze Pond. London SE1 9RT United Kingdom
| | - E Rakha
- Department of Histopathology The University of Nottingham Nottingham City Hospital, Hucknall Road Nottingham NG5 1PB United Kingdom
| | - AM Shaaban
- Department of Cellular Pathology, Queen Elizabeth Hospital Birmingham and Cancer and Genomic Sciences University of Birmingham, Mindelsohn Way Birmingham B15 2GW United Kingdom
| | - BY Tan
- Department of Anatomical Pathology, Singapore General Hospital College Rd Singapore 169856
| | - GM Tse
- Department of Anatomical and Cellular Pathology, Prince of Wales Hospital The Chinese University of Hong Kong, Ngan Shing Street Shatin Hong Kong
| | - PH Watson
- Department of Pathology, Biobanking and Biospecimen Research Services, Deeley Research Centre, BC Cancer Agency, 2410 Lee Ave Victoria BC V8R 6V5 Canada Victoria British Columbia Canada
| | - PH Tan
- Division of Pathology Singapore General Hospital Singapore
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Bonci EA, Țîțu Ș, Petrușan AM, Hossu C, Gâta VA, Ghomi MT, Kubelac PM, Bonci TI, Piciu A, Cosnarovici M, Hîțu L, Kirsch-Mangu AT, Pop DC, Lisencu IC, Achimaș-Cadariu P, Piciu D, Schmidt H, Fetica B. Does Surgical Margin Width Remain a Challenge for Triple-Negative Breast Cancer? A Retrospective Analysis. ACTA ACUST UNITED AC 2021; 57:medicina57030203. [PMID: 33652670 PMCID: PMC7996718 DOI: 10.3390/medicina57030203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/18/2021] [Accepted: 02/23/2021] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Local and distant relapse (LR, DR) in breast cancer vary according to its molecular subtypes, with triple-negative breast cancer (TNBC) being the most aggressive. The surgical resection margin width (SRMW) for breast-conserving surgery (BCS) has been intensely debated, especially for the aforementioned subtype. The aim of this study was to examine the impact of SRMW on LR following BCS in TNBC patients. Materials and Methods: We conducted a retrospective study including all patients with TNBC for whom BCS was performed between 2005 and 2014. Results: Final analysis included a total of 92 patients, with a median tumor size of 2.5 cm (range 0-5 cm) and no distant metastasis at the time of diagnosis. A total of 87 patients had received neoadjuvant and/or adjuvant chemotherapy, and all patients had received adjuvant whole-breast radiotherapy. After a median follow-up of 110.7 months (95% CI, 95.23-126.166), there were 5 local recurrences and 8 regional/distant recurrences with an overall LR rate of 5.4%. The risk of LR and DR was similar between groups of patients with several SRMW cut-off values. Conclusions: Our study supports a safe "no ink on tumor" approach for TNBC patients treated with BCS.
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Affiliation(s)
- Eduard-Alexandru Bonci
- 11th Department of Oncological Surgery and Gynecological Oncology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (E.-A.B.); (Ș.Ț.); (V.A.G.); (M.T.G.); (T.I.B.); (A.P.); (M.C.); (L.H.); (A.T.K.-M.); (D.C.P.); (P.A.-C.); (D.P.); (B.F.)
- Department of Surgical Oncology, “Prof. Dr. Ion Chiricuță” Institute of Oncology, 400015 Cluj-Napoca, Romania; (A.M.P.); (C.H.)
| | - Ștefan Țîțu
- 11th Department of Oncological Surgery and Gynecological Oncology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (E.-A.B.); (Ș.Ț.); (V.A.G.); (M.T.G.); (T.I.B.); (A.P.); (M.C.); (L.H.); (A.T.K.-M.); (D.C.P.); (P.A.-C.); (D.P.); (B.F.)
- Department of Surgical Oncology, “Prof. Dr. Ion Chiricuță” Institute of Oncology, 400015 Cluj-Napoca, Romania; (A.M.P.); (C.H.)
| | - Alexandru Marius Petrușan
- Department of Surgical Oncology, “Prof. Dr. Ion Chiricuță” Institute of Oncology, 400015 Cluj-Napoca, Romania; (A.M.P.); (C.H.)
| | - Claudiu Hossu
- Department of Surgical Oncology, “Prof. Dr. Ion Chiricuță” Institute of Oncology, 400015 Cluj-Napoca, Romania; (A.M.P.); (C.H.)
| | - Vlad Alexandru Gâta
- 11th Department of Oncological Surgery and Gynecological Oncology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (E.-A.B.); (Ș.Ț.); (V.A.G.); (M.T.G.); (T.I.B.); (A.P.); (M.C.); (L.H.); (A.T.K.-M.); (D.C.P.); (P.A.-C.); (D.P.); (B.F.)
- Department of Surgical Oncology, “Prof. Dr. Ion Chiricuță” Institute of Oncology, 400015 Cluj-Napoca, Romania; (A.M.P.); (C.H.)
| | - Morvarid Talaeian Ghomi
- 11th Department of Oncological Surgery and Gynecological Oncology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (E.-A.B.); (Ș.Ț.); (V.A.G.); (M.T.G.); (T.I.B.); (A.P.); (M.C.); (L.H.); (A.T.K.-M.); (D.C.P.); (P.A.-C.); (D.P.); (B.F.)
| | - Paul Milan Kubelac
- 11th Department of Oncological Surgery and Gynecological Oncology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (E.-A.B.); (Ș.Ț.); (V.A.G.); (M.T.G.); (T.I.B.); (A.P.); (M.C.); (L.H.); (A.T.K.-M.); (D.C.P.); (P.A.-C.); (D.P.); (B.F.)
- Department of Medical Oncology, “Prof. Dr. Ion Chiricuță” Institute of Oncology, 400015 Cluj-Napoca, Romania
- Correspondence: (P.M.K.); (I.C.L.)
| | - Teodora Irina Bonci
- 11th Department of Oncological Surgery and Gynecological Oncology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (E.-A.B.); (Ș.Ț.); (V.A.G.); (M.T.G.); (T.I.B.); (A.P.); (M.C.); (L.H.); (A.T.K.-M.); (D.C.P.); (P.A.-C.); (D.P.); (B.F.)
| | - Andra Piciu
- 11th Department of Oncological Surgery and Gynecological Oncology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (E.-A.B.); (Ș.Ț.); (V.A.G.); (M.T.G.); (T.I.B.); (A.P.); (M.C.); (L.H.); (A.T.K.-M.); (D.C.P.); (P.A.-C.); (D.P.); (B.F.)
- Department of Medical Oncology, “Prof. Dr. Ion Chiricuță” Institute of Oncology, 400015 Cluj-Napoca, Romania
| | - Maria Cosnarovici
- 11th Department of Oncological Surgery and Gynecological Oncology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (E.-A.B.); (Ș.Ț.); (V.A.G.); (M.T.G.); (T.I.B.); (A.P.); (M.C.); (L.H.); (A.T.K.-M.); (D.C.P.); (P.A.-C.); (D.P.); (B.F.)
- Department of Medical Oncology, “Prof. Dr. Ion Chiricuță” Institute of Oncology, 400015 Cluj-Napoca, Romania
| | - Liviu Hîțu
- 11th Department of Oncological Surgery and Gynecological Oncology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (E.-A.B.); (Ș.Ț.); (V.A.G.); (M.T.G.); (T.I.B.); (A.P.); (M.C.); (L.H.); (A.T.K.-M.); (D.C.P.); (P.A.-C.); (D.P.); (B.F.)
| | - Alexandra Timea Kirsch-Mangu
- 11th Department of Oncological Surgery and Gynecological Oncology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (E.-A.B.); (Ș.Ț.); (V.A.G.); (M.T.G.); (T.I.B.); (A.P.); (M.C.); (L.H.); (A.T.K.-M.); (D.C.P.); (P.A.-C.); (D.P.); (B.F.)
- Department of Radiotherapy, “Prof. Dr. Ion Chiricuță” Institute of Oncology, 400015 Cluj-Napoca, Romania
| | - Diana Cristina Pop
- 11th Department of Oncological Surgery and Gynecological Oncology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (E.-A.B.); (Ș.Ț.); (V.A.G.); (M.T.G.); (T.I.B.); (A.P.); (M.C.); (L.H.); (A.T.K.-M.); (D.C.P.); (P.A.-C.); (D.P.); (B.F.)
- Department of Radiotherapy, “Prof. Dr. Ion Chiricuță” Institute of Oncology, 400015 Cluj-Napoca, Romania
| | - Ioan Cosmin Lisencu
- 11th Department of Oncological Surgery and Gynecological Oncology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (E.-A.B.); (Ș.Ț.); (V.A.G.); (M.T.G.); (T.I.B.); (A.P.); (M.C.); (L.H.); (A.T.K.-M.); (D.C.P.); (P.A.-C.); (D.P.); (B.F.)
- Department of Surgical Oncology, “Prof. Dr. Ion Chiricuță” Institute of Oncology, 400015 Cluj-Napoca, Romania; (A.M.P.); (C.H.)
- Correspondence: (P.M.K.); (I.C.L.)
| | - Patriciu Achimaș-Cadariu
- 11th Department of Oncological Surgery and Gynecological Oncology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (E.-A.B.); (Ș.Ț.); (V.A.G.); (M.T.G.); (T.I.B.); (A.P.); (M.C.); (L.H.); (A.T.K.-M.); (D.C.P.); (P.A.-C.); (D.P.); (B.F.)
- Department of Surgical Oncology, “Prof. Dr. Ion Chiricuță” Institute of Oncology, 400015 Cluj-Napoca, Romania; (A.M.P.); (C.H.)
| | - Doina Piciu
- 11th Department of Oncological Surgery and Gynecological Oncology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (E.-A.B.); (Ș.Ț.); (V.A.G.); (M.T.G.); (T.I.B.); (A.P.); (M.C.); (L.H.); (A.T.K.-M.); (D.C.P.); (P.A.-C.); (D.P.); (B.F.)
- Department of Nuclear Medicine, “Prof. Dr. Ion Chiricuță” Institute of Oncology, 400015 Cluj-Napoca, Romania
| | - Hank Schmidt
- Division of Breast Surgery, Tisch Cancer Institute, Mount Sinai Health System, New York, NY 10029, USA;
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Bogdan Fetica
- 11th Department of Oncological Surgery and Gynecological Oncology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (E.-A.B.); (Ș.Ț.); (V.A.G.); (M.T.G.); (T.I.B.); (A.P.); (M.C.); (L.H.); (A.T.K.-M.); (D.C.P.); (P.A.-C.); (D.P.); (B.F.)
- Department of Anatomical Pathology, “Prof. Dr. Ion Chiricuță” Institute of Oncology, 400015 Cluj-Napoca, Romania
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Fabelo C, Selmic LE, Huang PC, Samuelson JP, Reagan JK, Kalamaras A, Wavreille V, Monroy GL, Marjanovic M, Boppart SA. Evaluating optical coherence tomography for surgical margin assessment of canine mammary tumours. Vet Comp Oncol 2020; 19:697-706. [PMID: 32562330 DOI: 10.1111/vco.12632] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/11/2020] [Accepted: 06/17/2020] [Indexed: 12/20/2022]
Abstract
Optical coherence tomography (OCT) uses near-infrared light waves to generate real-time, high-resolution images on the microscopic scale similar to low power histopathology. Previous studies have demonstrated the use of OCT for real-time surgical margin assessment for human breast cancer. The use of OCT for canine mammary tumours (CMT) could allow intra-operative visualisation of residual tumour at the surgical margins. The purpose of this study was to assess OCT imaging for the detection of incomplete tumour resection following CMT surgery. We hypothesized that the OCT images would have comparable features to histopathological images of tissues at the surgical margins of CMT resections along with a high sensitivity of OCT detection of incomplete surgical excision of CMT. Thirty surgical specimens were obtained from nineteen client-owned dogs undergoing surgical resection of CMT. OCT image appearance and characteristics of adipose tissue, skin, mammary tissue and mammary tumour at the surgical margins were distinct and different. The OCT images of normal and abnormal tissues at the surgical margins were utilized to develop a dataset of OCT images for observer evaluation. The sensitivity and specificity for ex vivo images were 83.3% and 82.0% (observer 1) and 70.0% and 67.9% (observer 2). The sensitivity and specificity for in vivo images were 70.0% and 89.3% (observer 1) and 76.7% and 67.9% (observer 2). These results indicate a potential use of OCT for surgical margin assessment for CMT to optimize surgical intervention and clinical outcomes. Improved training and experience of observers may improve sensitivity and specificity.
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Affiliation(s)
- Carolina Fabelo
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Ohio State University, Columbus, Ohio, USA
| | - Laura E Selmic
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Ohio State University, Columbus, Ohio, USA
| | - Pin-Cheh Huang
- Department of Bioengineering, University of Illinois at Urbana-Champaign, Champaign, Illinois, USA.,Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, Champaign, Illinois, USA
| | - Jonathan P Samuelson
- Department of Veterinary Clinical Medicine, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
| | - Jennifer K Reagan
- Department of Surgery, Seattle Veterinary Specialists-Downtown, Seattle, Washington, USA
| | - Alexandra Kalamaras
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Ohio State University, Columbus, Ohio, USA
| | - Vincent Wavreille
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Ohio State University, Columbus, Ohio, USA
| | - Guillermo L Monroy
- Department of Bioengineering, University of Illinois at Urbana-Champaign, Champaign, Illinois, USA.,Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, Champaign, Illinois, USA
| | - Marina Marjanovic
- Department of Bioengineering, University of Illinois at Urbana-Champaign, Champaign, Illinois, USA.,Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, Champaign, Illinois, USA.,Carle Illinois College of Medicine, University of Illinois at Urbana-Champaign, Champaign, Illinois, USA
| | - Stephen A Boppart
- Department of Bioengineering, University of Illinois at Urbana-Champaign, Champaign, Illinois, USA.,Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, Champaign, Illinois, USA.,Carle Illinois College of Medicine, University of Illinois at Urbana-Champaign, Champaign, Illinois, USA.,Department of Electrical and Computer Engineering, University of Illinois at Urbana-Champaign, Champaign, Illinois, USA.,Cancer Center at Illinois, University of Illinois at Urbana-Champaign, Champaign, Illinois, USA
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4
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Miligy IM, Toss MS, Khout H, Whisker L, Burrell HC, Ellis IO, Green AR, Macmillan D, Rakha EA. Surgical management of ductal carcinoma in situ of the breast: A large retrospective study from a single institution. Breast J 2019; 25:1143-1153. [PMID: 31318120 DOI: 10.1111/tbj.13425] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 01/28/2019] [Accepted: 02/20/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Management of breast ductal carcinoma in situ (DCIS) has various approaches with distinct institutional specific practice. Here, we review DCIS management in a single institution with emphasize on re-operation rates and outcome. METHODS Breast ductal carcinoma in situ cases diagnosed at the Nottingham Breast Institute between 1987 and 2017 were identified (n = 1249). Clinicopathological data were collected. Cases were histologically reviewed, and different factors associated with primary operation selection, re-excision, presence of residual tumor in the re-excision specimens, use of radiotherapy and ipsilateral recurrences were analyzed. RESULTS 34% of DCIS patients were initially treated by mastectomy and were more frequently symptomatic, of high nuclear tumor grade, size >40 mm, and associated with comedo necrosis and Paget's disease of the nipple. Further surgery was due to involved or narrow surgical margins. Residual tumor tissue was detected in 53% of the re-excision specimens. Re-excision rates of patients treated with breast-conserving surgery (BCS) were reduced from approximately 70% to 23%, and the final mastectomy rates decreased from 60% to 20%. Changes in surgical practice with acceptance of smaller excision margins and more frequent use of local radiotherapy have led to a significant decrease not only in the re-excision rate but also in the final mastectomy rate together with non-significant reduction in 5- and 10-year local recurrence rates. CONCLUSION Although BCS is increasingly the preferred primary surgical option for DCIS management, a proportion of low-risk DCIS patients continue to undergo re-excision surgery or completion mastectomy. Despite acceptance of smaller margins, recurrence rate is decreasing.
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Affiliation(s)
- Islam M Miligy
- Division of Cancer and Stem Cells, Nottingham Breast Cancer Research Centre, School of Medicine, Nottingham City Hospital, The University of Nottingham, Nottingham, UK
| | - Michael S Toss
- Division of Cancer and Stem Cells, Nottingham Breast Cancer Research Centre, School of Medicine, Nottingham City Hospital, The University of Nottingham, Nottingham, UK
| | - Hazem Khout
- Nottingham Breast Institute, Nottingham City Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Lisa Whisker
- Nottingham Breast Institute, Nottingham City Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Helen C Burrell
- Nottingham Breast Institute, Nottingham City Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ian O Ellis
- Division of Cancer and Stem Cells, Nottingham Breast Cancer Research Centre, School of Medicine, Nottingham City Hospital, The University of Nottingham, Nottingham, UK.,Nottingham Breast Institute, Nottingham City Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Department of Histopathology, School of Medicine, Nottingham City Hospital, The University of Nottingham, Nottingham, UK
| | - Andrew R Green
- Division of Cancer and Stem Cells, Nottingham Breast Cancer Research Centre, School of Medicine, Nottingham City Hospital, The University of Nottingham, Nottingham, UK
| | - Douglas Macmillan
- Nottingham Breast Institute, Nottingham City Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Emad A Rakha
- Division of Cancer and Stem Cells, Nottingham Breast Cancer Research Centre, School of Medicine, Nottingham City Hospital, The University of Nottingham, Nottingham, UK.,Nottingham Breast Institute, Nottingham City Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Department of Histopathology, School of Medicine, Nottingham City Hospital, The University of Nottingham, Nottingham, UK
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Hanna WM, Parra-Herran C, Lu FI, Slodkowska E, Rakovitch E, Nofech-Mozes S. Ductal carcinoma in situ of the breast: an update for the pathologist in the era of individualized risk assessment and tailored therapies. Mod Pathol 2019; 32:896-915. [PMID: 30760859 DOI: 10.1038/s41379-019-0204-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 12/13/2018] [Accepted: 12/13/2018] [Indexed: 12/30/2022]
Abstract
Ductal carcinoma in situ (DCIS) is a neoplastic proliferation of mammary ductal epithelial cells confined to the ductal-lobular system, and a non-obligate precursor of invasive disease. While there has been a significant increase in the diagnosis of DCIS in recent years due to uptake of mammography screening, there has been little change in the rate of invasive recurrence, indicating that a large proportion of patients diagnosed with DCIS will never develop invasive disease. The main issue for clinicians is how to reliably predict the prognosis of DCIS in order to individualize patient treatment, especially as treatment ranges from surveillance only, breast-conserving surgery only, to breast-conserving surgery plus radiotherapy and/or hormonal therapy, and mastectomy with or without radiotherapy. We conducted a semi-structured literature review to address the above issues relating to "pure" DCIS. Here we discuss the pathology of DCIS, risk factors for recurrence, biomarkers and molecular signatures, and disease management. Potential mechanisms of progression from DCIS to invasive cancer and problems faced by clinicians and pathologists in diagnosing and treating this disease are also discussed. Despite the tremendous research efforts to identify accurate risk stratification predictors of invasive recurrence and response to radiotherapy and endocrine therapy, to date there is no simple, well-validated marker or group of variables for risk estimation, particularly in the setting of adjuvant treatment after breast-conserving surgery. Thus, the standard of care to date remains breast-conserving surgery plus radiotherapy, with or without hormonal therapy. Emerging tools, such as pathologic or biologic markers, may soon change such practice. Our review also includes recent advances towards innovative treatment strategies, including targeted therapies, immune modulators, and vaccines.
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Affiliation(s)
- Wedad M Hanna
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
| | - Carlos Parra-Herran
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Fang-I Lu
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Elzbieta Slodkowska
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Eileen Rakovitch
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Sharon Nofech-Mozes
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
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6
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Krishnamurthy K, Febres-Aldana CA, Alghamdi S, Mesko T, Paramo J, Poppiti RJ. Comparative analysis of margin status in breast conservation surgery and its correlation with subsequent re-excision findings. Pathologica 2019; 111:31-36. [PMID: 31217620 PMCID: PMC8138535 DOI: 10.32074/1591-951x-64-18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 11/11/2019] [Indexed: 11/30/2022] Open
Abstract
Purpose Breast-conservation surgery (BCS) has become a standard treatment option for invasive breast carcinoma (IBC) and ductal carcinoma in situ (DCIS). The strongest predictor of local recurrence remains the surgical margin status. We evaluated the margin positivity by quantifying the tumor on positive margins and analyzing the histologic factors including type and extent in determining the likelihood of residual disease upon re-excision. Method Retrospective analysis of 210 BCS performed at Mount Sinai Medical Center from the period of January 2011 - December 2017 revealed that 58 had IBC, DCIS, or both, with positive margins that were followed by re-excision. Result The margins had IBC in 18 (31%), DCIS in 32 (55.2%) and both in 8 (13%) cases. Thirty-eight cases (65.5%) were free of carcinoma on re-excision. Of 40 cases with margins positive for DCIS, 16 (40%) had residual DCIS. Of 26 cases with IBC at the margins, and 5 had residual disease (19%). This difference was statistically significant (p = 0.002). Of 21 cases with extensive DCIS, 12 had residual disease (p = 0.02) as compared to only 4 out of 19 without extensive DCIS. None of the cases with clinging/micro-papillary DCIS had residual disease, while 51% of the other types (solid, cribriform, come-do) had residual disease (p = 0.02). The area of DCIS as measured on the involved margin correlated with the amount of residual disease on re-excision (p = 0.03). Conclusion Margins positive for DCIS are more likely to have residual disease on re-excision in comparison to margins positive for only IBC. The type and extent of DCIS appears to influence the likelihood of residual disease.
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Affiliation(s)
- K Krishnamurthy
- Arkadi Rywlin Department of Pathology and Laboratory Medicine, Mount Sinai Medical Center, Miami, Florida
| | - C A Febres-Aldana
- Arkadi Rywlin Department of Pathology and Laboratory Medicine, Mount Sinai Medical Center, Miami, Florida
| | - S Alghamdi
- Arkadi Rywlin Department of Pathology and Laboratory Medicine, Mount Sinai Medical Center, Miami, Florida
| | - T Mesko
- Surgical Oncology, Mount Sinai Medical Center, Miami, Florida
| | - J Paramo
- Surgical Oncology, Mount Sinai Medical Center, Miami, Florida
| | - R J Poppiti
- Arkadi Rywlin Department of Pathology and Laboratory Medicine, Mount Sinai Medical Center, Miami, Florida.,FIU Herbert Wertheim college of Medicine, Miami, Florida
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7
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Naz S, Masroor I, Afzal S, Mirza W, Butt S, Sajjad Z, Ahmad A. Accuracy of Specimen Radiography in Assessing Complete Local Excision with Breast-Conservation Surgery. Asian Pac J Cancer Prev 2018; 19:763-767. [PMID: 29582632 PMCID: PMC5980853 DOI: 10.22034/apjcp.2018.19.3.763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: The aim of this study was to evaluate the accuracy of “X- ray examination of surgically resected specimen‘‘ in assessing complete local excision (CLE). Materials and Methods: In this retrospective cross sectional study, data were collected for all female breast cancer cases who underwent breast-conserving surgery after needle localization of mammographically visible disease. Males, patients with mammographically invisible disease and cases with benign or inconclusive histopathology, those undergoing modified radical mastectomy and individuals with dense breast parenchyma were excluded. We evaluated radiography of resected specimens to assess margin spiculation, distance of mass/microcalcification from the excised margin, presence of a mass, and presence of any adjacent microcalcification, Other features including mass size, nuclear grade and patient’s age were also recorded and all were analyzed for any association with CLE. Results: Absence of adjacent microcalcification and the presence of a mass on radiographs showed significant associations with CLE, but no links were evident with other features. Specimen radiography was found to be a sufficient tool to predict CLE with a positive predictive value of 83.3%, a sensitivity of 80.7% and a specificity of 81%. Conclusion: Specimen radiography is an important and sensitive tool to predict CLE.
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Affiliation(s)
- Saira Naz
- Departments of Diagnostic Radiology and Medicine, Aga Khan University Hospital, Karachi, Pakistan.
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8
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Guidi AJ, Tworek JA, Mais DD, Souers RJ, Blond BJ, Brown RW. Breast Specimen Processing and Reporting With an Emphasis on Margin Evaluation: A College of American Pathologists Survey of 866 Laboratories. Arch Pathol Lab Med 2018; 142:496-506. [PMID: 29328775 DOI: 10.5858/arpa.2016-0626-cp] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT - The College of American Pathologists (CAP) developed protocols for reporting pathologic characteristics of breast cancer specimens, including margin status. The Society of Surgical Oncology (SSO) and the American Society for Radiation Oncology (ASTRO) published treatment guidelines regarding margins in patients with invasive cancer; and SSO, ASTRO, and the American Society of Clinical Oncology (ASCO) recently published guidelines for patients with ductal carcinoma in situ. OBJECTIVE - To assess current practices among pathologists with regard to the processing/reporting of breast specimens, assess compliance with CAP cancer protocols, and assess alignment with SSO/ASTRO and SSO/ASTRO/ASCO guidelines. DESIGN - A survey concerning breast specimen processing/reporting was distributed to pathologists enrolled in the CAP Performance Improvement Program in Surgical Pathology. RESULTS - Ninety-four percent (716 of 764 respondents) and 91% (699 of 769 respondents) define positive margins as "tumor on ink" for invasive cancer and ductal carcinoma in situ, respectively, in compliance with CAP cancer protocols and with SSO/ASTRO and SSO/ASTRO/ASCO guidelines. Of 791 respondents who provided details regarding methods for margin evaluation, 608 (77%) exclusively examine perpendicular margins, facilitating guideline compliance. However, 183 of 791 respondents (23%) examine en face margins in at least a subset of specimens, which may preclude guideline compliance in some cases. When separate cavity (shave) margins are examined, while 517 of 586 respondents (88%) ink these specimens, 69 of 586 (12%) do not, and this may also preclude guideline compliance in some cases. CONCLUSIONS - A substantial proportion of survey participants report margin status for breast cancer specimens in a manner consistent with CAP cancer protocols, and in alignment with SSO/ASTRO and SSO/ASTRO/ASCO guidelines. However, there are opportunities for some laboratories to modify procedures in order to facilitate more complete adherence to guidelines.
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Affiliation(s)
| | | | | | | | | | - Richard W Brown
- From the Department of Pathology, Newton-Wellesley Hospital, Newton, Massachusetts (Dr Guidi); the Department of Pathology, St. Joseph Mercy Hospital, Ann Arbor, Michigan (Dr Tworek); the Department of Pathology, University of Texas Health Sciences Center University Hospital, San Antonio (Dr Mais); Biostatistics (Ms Souers) and Surveys - Cytopathology (Ms Blond), College of American Pathologists, Northfield, Illinois; and the Department of Pathology, Memorial Hermann Southwest Hospital, Houston, Texas (Dr Brown)
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9
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Lazzeroni M, Dunn BK, Pruneri G, Jereczek-Fossa BA, Orecchia R, Bonanni B, DeCensi A. Adjuvant therapy in patients with ductal carcinoma in situ of the breast: The Pandora's box. Cancer Treat Rev 2017; 55:1-9. [PMID: 28262606 DOI: 10.1016/j.ctrv.2017.01.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 01/26/2017] [Accepted: 01/30/2017] [Indexed: 12/23/2022]
Abstract
Most patients with ductal carcinoma in situ of the breast (DCIS) are eligible for breast conservation treatment. The key management decision is whether to add radiotherapy and/or endocrine therapy to minimize the risk of a subsequent recurrence. Recent analyses indicating a lack of benefit in terms of breast cancer-associated mortality have suggested that more conservative approaches, omitting adjuvant therapy or even surgery, may be advisable in selected patients. These mortality observations are directly influenced by widespread use of mammographic screening which has opened a Pandora's box of subclinical DCIS and early invasive lesions. Confusion as to how aggressively such possibly indolent lesions should be treated has led to misunderstandings among patients and medical professionals. While awaiting further prospective evidence from clinical trials, we endorse an active treatment of DCIS as the standard of care. Our rationale is twofold: invasive recurrences are associated with an increase in breast cancer mortality, which is not the only relevant endpoint for DCIS. The benefit of complete surgical excision, adjuvant radiotherapy and endocrine treatment in preventing recurrence and invasive progression has been demonstrated in DCIS. The challenge now is how to identify DCIS patients who will not progress to invasive carcinoma even without complete excision and, at the other extreme, those patients at the highest risk who require mastectomy for local control. The current controversies over whether and which adjuvant therapy should be implemented can at least in part be addressed by developing effective doctor-patient communications that enable mutual understanding about the management of this biologically heterogeneous disease.
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Affiliation(s)
- Matteo Lazzeroni
- Divisions of Cancer Prevention and Genetics, European Institute of Oncology, Milan, Italy
| | - Barbara K Dunn
- Division of Cancer Prevention, National Cancer Institute, Bethesda, MD 20892, USA
| | - Giancarlo Pruneri
- Pathology, European Institute of Oncology, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Radiotherapy, European Institute of Oncology, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Italy
| | - Roberto Orecchia
- Radiotherapy, European Institute of Oncology, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Italy
| | - Bernardo Bonanni
- Divisions of Cancer Prevention and Genetics, European Institute of Oncology, Milan, Italy
| | - Andrea DeCensi
- Divisions of Cancer Prevention and Genetics, European Institute of Oncology, Milan, Italy; Division of Medical Oncology, E.O. Ospedali Galliera, Genoa, Italy; Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, United Kingdom.
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10
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Toss MS, Pinder SE, Green AR, Thomas J, Morgan DAL, Robertson JFR, Ellis IO, Rakha EA. Breast conservation in ductal carcinomain situ(DCIS): what defines optimal margins? Histopathology 2016; 70:681-692. [DOI: 10.1111/his.13116] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Michael S Toss
- Department of Histopathology, Division of Cancer and Stem Cells, School of Medicine; The University of Nottingham, Nottingham City Hospital; Nottingham UK
| | - Sarah E Pinder
- Department of Research Oncology; King's College London, Guy's Hospital; London UK
| | - Andrew R Green
- Department of Histopathology, Division of Cancer and Stem Cells, School of Medicine; The University of Nottingham, Nottingham City Hospital; Nottingham UK
| | - Jeremy Thomas
- Department of Pathology; Western General Hospital; Edinburgh UK
| | - David A L Morgan
- Department of Oncology, Division of Cancer and Stem Cells, School of Medicine; The University of Nottingham, Nottingham City Hospital; Nottingham UK
| | - John F R Robertson
- Division of Breast Surgery, Graduate Entry Medicine and Health School (GEMS); University of Nottingham, Royal Derby Hospital; Derby UK
| | - Ian O Ellis
- Department of Histopathology, Division of Cancer and Stem Cells, School of Medicine; The University of Nottingham, Nottingham City Hospital; Nottingham UK
| | - Emad A Rakha
- Department of Histopathology, Division of Cancer and Stem Cells, School of Medicine; The University of Nottingham, Nottingham City Hospital; Nottingham UK
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11
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Allen WM, Chin L, Wijesinghe P, Kirk RW, Latham B, Sampson DD, Saunders CM, Kennedy BF. Wide-field optical coherence micro-elastography for intraoperative assessment of human breast cancer margins. BIOMEDICAL OPTICS EXPRESS 2016; 7:4139-4153. [PMID: 27867721 PMCID: PMC5102536 DOI: 10.1364/boe.7.004139] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 08/20/2016] [Accepted: 08/24/2016] [Indexed: 05/18/2023]
Abstract
Incomplete excision of malignant tissue is a major issue in breast-conserving surgery, with typically 20 - 30% of cases requiring a second surgical procedure arising from postoperative detection of an involved margin. We report advances in the development of a new intraoperative tool, optical coherence micro-elastography, for the assessment of tumor margins on the micro-scale. We demonstrate an important step by conducting whole specimen imaging in intraoperative time frames with a wide-field scanning system acquiring mosaicked elastograms with overall dimensions of ~50 × 50 mm, large enough to image an entire face of most lumpectomy specimens. This capability is enabled by a wide-aperture annular actuator with an internal diameter of 65 mm. We demonstrate feasibility by presenting elastograms recorded from freshly excised human breast tissue, including from a mastectomy, lumpectomies and a cavity shaving.
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Affiliation(s)
- Wes M. Allen
- Optical + Biomedical Engineering Laboratory, School of Electrical, Electronic & Computer Engineering, The University of Western Australia, 35 Stirling Highway, Perth, WA 6009, Australia
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, 6 Verdun Street, Nedlands, WA 6009, Australia
| | - Lixin Chin
- Optical + Biomedical Engineering Laboratory, School of Electrical, Electronic & Computer Engineering, The University of Western Australia, 35 Stirling Highway, Perth, WA 6009, Australia
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, 6 Verdun Street, Nedlands, WA 6009, Australia
| | - Philip Wijesinghe
- Optical + Biomedical Engineering Laboratory, School of Electrical, Electronic & Computer Engineering, The University of Western Australia, 35 Stirling Highway, Perth, WA 6009, Australia
| | - Rodney W. Kirk
- Optical + Biomedical Engineering Laboratory, School of Electrical, Electronic & Computer Engineering, The University of Western Australia, 35 Stirling Highway, Perth, WA 6009, Australia
- Centre for Nanoscale BioPhotonics, Faculty of Health Science, University of Adelaide, Adelaide, SA 5005, Australia
| | - Bruce Latham
- PathWest, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, WA 6150, Australia
| | - David D. Sampson
- Optical + Biomedical Engineering Laboratory, School of Electrical, Electronic & Computer Engineering, The University of Western Australia, 35 Stirling Highway, Perth, WA 6009, Australia
- Centre for Microscopy, Characterisation & Analysis, The University of Western Australia, 35 Stirling Highway, Perth, WA 6009, Australia
| | - Christobel M. Saunders
- School of Surgery, The University of Western Australia, 35 Stirling Highway, Perth, WA 6009, Australia
- Breast Centre, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, WA 6150, Australia
- Breast Clinic, Royal Perth Hospital, 197 Wellington Street, Perth, WA 6000, Australia
| | - Brendan F. Kennedy
- Optical + Biomedical Engineering Laboratory, School of Electrical, Electronic & Computer Engineering, The University of Western Australia, 35 Stirling Highway, Perth, WA 6009, Australia
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, 6 Verdun Street, Nedlands, WA 6009, Australia
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12
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Guerrieri-Gonzaga A, Sestak I, Lazzeroni M, Serrano D, Rotmensz N, Cazzaniga M, Varricchio C, Pruneri G, Leonardi MC, Orecchia R, Galimberti V, Bonanni B, DeCensi A. Benefit of low-dose tamoxifen in a large observational cohort of high risk ER positive breast DCIS. Int J Cancer 2016; 139:2127-34. [DOI: 10.1002/ijc.30254] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 06/14/2016] [Accepted: 06/21/2016] [Indexed: 11/09/2022]
Affiliation(s)
| | - Ivana Sestak
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London; United Kingdom
| | - Matteo Lazzeroni
- Divisions of Cancer Prevention and Genetics; European Institute of Oncology Milan; Italy
| | - Davide Serrano
- Divisions of Cancer Prevention and Genetics; European Institute of Oncology Milan; Italy
| | - Nicole Rotmensz
- Epidemiology and Biostatistics; European Institute of Oncology Milan; Italy
| | - Massimiliano Cazzaniga
- Divisions of Cancer Prevention and Genetics; European Institute of Oncology Milan; Italy
| | - Clara Varricchio
- Divisions of Cancer Prevention and Genetics; European Institute of Oncology Milan; Italy
| | - Giancarlo Pruneri
- Pathology; European Institute of Oncology Milan; Italy
- University of Milan, School of Medicine; Milan Italy
| | | | - Roberto Orecchia
- University of Milan, School of Medicine; Milan Italy
- Radiotherapy; European Institute of Oncology Milan; Italy
| | | | - Bernardo Bonanni
- Divisions of Cancer Prevention and Genetics; European Institute of Oncology Milan; Italy
| | - Andrea DeCensi
- Divisions of Cancer Prevention and Genetics; European Institute of Oncology Milan; Italy
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London; United Kingdom
- Division of Medical Oncology; E.O. Ospedali Galliera; Genoa Italy
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13
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Clarke GM, Holloway CMB, Zubovits JT, Nofech-Mozes S, Liu K, Murray M, Wang D, Yaffe MJ. Whole-mount pathology of breast lumpectomy specimens improves detection of tumour margins and focality. Histopathology 2016; 69:35-44. [DOI: 10.1111/his.12912] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 11/27/2015] [Indexed: 11/26/2022]
Affiliation(s)
- Gina M Clarke
- Physical Sciences; Sunnybrook Research Institute; Toronto Ontario Canada
| | - Claire M B Holloway
- Department of Surgery; Sunnybrook Health Sciences Centre; Toronto Ontario Canada
- Department of Surgery; Faculty of Medicine; University of Toronto; Toronto Ontario Canada
| | - Judit T Zubovits
- Department of Pathology; The Scarborough Hospital; Toronto Ontario Canada
- Department of Laboratory Medicine and Pathobiology; University of Toronto; Toronto Ontario Canada
| | - Sharon Nofech-Mozes
- Department of Laboratory Medicine and Pathobiology; University of Toronto; Toronto Ontario Canada
- Department of Anatomic Pathology; Sunnybrook Health Sciences Centre; Toronto Ontario Canada
| | - Kela Liu
- Physical Sciences; Sunnybrook Research Institute; Toronto Ontario Canada
| | - Mayan Murray
- Physical Sciences; Sunnybrook Research Institute; Toronto Ontario Canada
| | - Dan Wang
- Physical Sciences; Sunnybrook Research Institute; Toronto Ontario Canada
| | - Martin J Yaffe
- Physical Sciences; Sunnybrook Research Institute; Toronto Ontario Canada
- Departments of Medical Biophysics and Medical Imaging; University of Toronto; Toronto Ontario Canada
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14
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Edwards BL, Guidry CA, Larson KN, Novicoff WM, Harvey JA, Schroen AT. Does Mammographic Density have an Impact on the Margin Re-excision Rate After Breast-Conserving Surgery? Ann Surg Oncol 2015; 23:782-8. [PMID: 26471488 DOI: 10.1245/s10434-015-4917-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Limited and conflicting data exist on an association between mammographic density (MD) and re-excision rates after breast-conserving surgery (BCS). Additionally, the correlation of MD with resection of unnecessary margins during initial BCS is unknown. METHODS All women with a diagnosis of breast cancer from 2003 to 2012 and enrolled in a larger study on MD were evaluated. Operative and pathology reports were reviewed to determine margin resection and involvement. Mammographic density was determined both by breast imaging-reporting and data system (BI-RADS) classification and by an automated software program (Volpara Solutions). Additional margins were deemed unnecessary if the lumpectomy specimen margin was free of invasive tumor [≥2 mm for ductal carcinoma in situ (DCIS)] or if further re-excision was needed. RESULTS Of 655 patients, 398 (60.8%) had BCS, whereas 226 (34.5%) underwent initial mastectomy. The women with denser breasts (BI-RADS 3 or 4) underwent initial mastectomy more frequently than the women with less dense breasts (40.0 vs. 30.5%, respectively; p = 0.0118). Of the patients with BCS, 166 (41.7%) required separate re-excision. Additional margins were taken during BCS in 192 (48.2%) patients, with 151 (78.6%) proving to be unnecessary. In the bivariable analysis, the patients with denser breasts according to BI-RADS classification and volumetric density showed a trend toward requiring more frequent re-excision, but this association was not seen in the multivariable analysis. The rate of unnecessary margins did not differ by breast density. In the multivariate analysis, the re-excision rates increased with DCIS (p < 0.0003) and decreased with resection of additional margins (p = 0.0043). CONCLUSIONS Mammographic density is not associated with an increased need for re-excision or resection of unnecessary margins at initial BCS.
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Affiliation(s)
- Brandy L Edwards
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | | | - Krista N Larson
- School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Wendy M Novicoff
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Jennifer A Harvey
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA
| | - Anneke T Schroen
- Department of Surgery, University of Virginia, Charlottesville, VA, USA. .,Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA.
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15
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Chung A, Gangi A, Amersi F, Bose S, Zhang X, Giuliano A. Impact of Consensus Guidelines by the Society of Surgical Oncology and the American Society for Radiation Oncology on Margins for Breast-Conserving Surgery in Stages 1 and 2 Invasive Breast Cancer. Ann Surg Oncol 2015; 22 Suppl 3:S422-7. [PMID: 26310280 DOI: 10.1245/s10434-015-4829-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND This study aimed to evaluate the impact that the release of consensus guidelines for margins in breast-conserving surgery (BCS) had on re-excision rates. METHODS A retrospective review examined a prospectively maintained database of patients who had operable invasive breast cancer treated with BCS at the authors' institution. The patients were divided into two groups: (1) those with a diagnosis determined from 1 July 2011 to 31 July 2013 (before release of the guidelines) and (2) those with a diagnosis determined from 1 February 2014 to 31 July 2014 (after release of the guidelines). The groups were evaluated with respect to patient and tumor characteristics, re-excision rates, and reasons for re-excision. RESULTS A total of 846 cases of BCS were managed: 597 in group 1 and 249 in group 2. Re-excision rates were significantly reduced after release of the consensus guidelines (p = 0.03). Re-excisions were performed for 115 (19 %) of 597 patients in group 1 and 32 (13 %) of 249 patients in group 2. After release of the guidelines, re-excisions were performed for positive margins, as defined by the consensus statement, in 25 (78 %) of 32 cases. The two groups did not differ significantly in terms of age, tumor size, grade, nodal status, estrogen receptor status, progesterone receptor status, or human epidermal growth factor receptor 2 status. Group 1 had more tumors of mixed ductal and lobular histology than group 2, and group 2 had more lobular tumors than group 1 (p = 0.02). CONCLUSIONS The consensus guidelines on margins for BCS were applied for 78 % of the patients who underwent re-excision and resulted in a significant reduction in re-excision rates.
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Affiliation(s)
- A Chung
- Division of Surgical Oncology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - A Gangi
- Division of Surgical Oncology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - F Amersi
- Division of Surgical Oncology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - S Bose
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - X Zhang
- Department of Biostatistics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - A Giuliano
- Division of Surgical Oncology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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16
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Tang R, Coopey SB, Specht MC, Lei L, Gadd MA, Hughes KS, Brachtel EF, Smith BL. Lumpectomy specimen margins are not reliable in predicting residual disease in breast conserving surgery. Am J Surg 2014; 210:93-8. [PMID: 25613784 DOI: 10.1016/j.amjsurg.2014.09.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 09/06/2014] [Accepted: 09/15/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND In breast conserving surgery, the concordance between lumpectomy margin (LM) status and the status of the corresponding lumpectomy cavity remains uncertain. METHODS We analyzed pathology reports of lumpectomies from 2004 to 2006. We included those which contained both ink-directed LM and complete (≥4) separate corresponding shaved cavity margins (SCMs). SCM pathology was used as a surrogate for lumpectomy cavity status, to determine the predictive value of LM for residual disease. RESULTS Pathology from 1,201 pairs of LM and SCM from 242 patients was compared. LM status predicted corresponding lumpectomy cavity status with 50.9% sensitivity, 69.5% specificity, 35% positive predictive value, and 81.4% negative predictive value, giving an overall accuracy of 64.9%. CONCLUSIONS Oriented LMs are not reliable for predicting lumpectomy cavity status, and therefore not reliable for directing re-excision. Taking complete, oriented SCMs at the time of lumpectomy may improve accuracy compared with traditional LM assessment.
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Affiliation(s)
- Rong Tang
- Division of Surgical Oncology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Division of Breast Surgery, Hunan Provincial Tumor Hospital, The Affiliated Tumor Hospital of Xiangya Medical School of Central South University, Changsha 410013, China
| | - Suzanne B Coopey
- Division of Surgical Oncology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Michelle C Specht
- Division of Surgical Oncology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Lan Lei
- Division of Surgical Oncology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Michele A Gadd
- Division of Surgical Oncology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Kevin S Hughes
- Division of Surgical Oncology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Elena F Brachtel
- Department of Pathology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Barbara L Smith
- Division of Surgical Oncology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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17
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Morrow M. Margins in breast-conserving therapy: have we lost sight of the big picture? Expert Rev Anticancer Ther 2014; 8:1193-6. [DOI: 10.1586/14737140.8.8.1193] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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18
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Bleicher RJ. Breast magnetic resonance imaging as it is, in contrast to how we wish it to be. J Clin Oncol 2014; 32:370-2. [PMID: 24395864 DOI: 10.1200/jco.2013.54.0039] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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19
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Imaging-assisted large-format breast pathology: program rationale and development in a nonprofit health system in the United States. Int J Breast Cancer 2012; 2012:171792. [PMID: 23316372 PMCID: PMC3534362 DOI: 10.1155/2012/171792] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 10/10/2012] [Indexed: 11/17/2022] Open
Abstract
Modern breast imaging, including magnetic resonance imaging, provides an increasingly clear depiction of breast cancer extent, often with suboptimal pathologic confirmation. Pathologic findings guide management decisions, and small increments in reported tumor characteristics may rationalize significant changes in therapy and staging. Pathologic techniques to grossly examine resected breast tissue have changed little during this era of improved breast imaging and still rely primarily on the techniques of gross inspection and specimen palpation. Only limited imaging information is typically conveyed to pathologists, typically in the form of wire-localization images from breast-conserving procedures. Conventional techniques of specimen dissection and section submission destroy the three-dimensional integrity of the breast anatomy and tumor distribution. These traditional methods of breast specimen examination impose unnecessary limitations on correlation with imaging studies, measurement of cancer extent, multifocality, and margin distance. Improvements in pathologic diagnosis, reporting, and correlation of breast cancer characteristics can be achieved by integrating breast imagers into the specimen examination process and the use of large-format sections which preserve local anatomy. This paper describes the successful creation of a large-format pathology program to routinely serve all patients in a busy interdisciplinary breast center associated with a community-based nonprofit health system in the United States.
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20
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Wei S, Kragel CP, Zhang K, Hameed O. Factors associated with residual disease after initial breast-conserving surgery for ductal carcinoma in situ. Hum Pathol 2012; 43:986-93. [DOI: 10.1016/j.humpath.2011.09.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Revised: 09/09/2011] [Accepted: 09/14/2011] [Indexed: 11/29/2022]
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21
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Lambert K, Patani N, Mokbel K. Ductal carcinoma in situ: recent advances and future prospects. Int J Surg Oncol 2012; 2012:347385. [PMID: 22675624 PMCID: PMC3362914 DOI: 10.1155/2012/347385] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2011] [Accepted: 02/22/2012] [Indexed: 01/15/2023] Open
Abstract
Introduction. This article reviews current management strategies for DCIS in the context of recent randomised trials, including the role of sentinel lymph node biopsy (SLNB), adjuvant radiotherapy (RT) and endocrine treatment. Methods. Literature review facilitated by Medline, PubMed, Embase and Cochrane databases. Results. DCIS should be managed in the context of a multidisciplinary team. Local control depends upon clear surgical margins (at least 2 mm is generally acceptable). SLNB is not routine, but can be considered in patients undergoing mastectomy (Mx) with risk factors for occult invasion. RT following BCS significantly reduces local recurrence (LR), particularly in those at high-risk. There remains a lack of level-1 evidence supporting omission of adjuvant RT in selected low-risk cases. Large, multi-centric or recurrent lesions should be treated by Mx and immediate reconstruction should be discussed. Adjuvant hormonal treatment may reduce the risk of LR in selected cases with hormone sensitive disease. Conclusion. Further research is required to determine the role of new RT regimes and endocrine therapies. Biological profiling and molecular analysis represent an opportunity to improve our understanding of tumour biology in DCIS to rationalise treatment. Reliable identification of low-risk lesions could allow treatment to be less radical.
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Affiliation(s)
- Kelly Lambert
- The Breast Unit, University Hospitals Leicester, Leicester LE3 9QP, UK
| | - Neill Patani
- The London Breast Institute, The Princess Grace Hospital, London W1U 5NY, UK
| | - Kefah Mokbel
- The London Breast Institute, The Princess Grace Hospital, London W1U 5NY, UK
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Orsaria P, Granai AV, Venditti D, Petrella G, Buonomo O. Investigational Paradigms in Downscoring and Upscoring DCIS: Surgical Management Review. Int J Surg Oncol 2012; 2012:560493. [PMID: 22666571 PMCID: PMC3362033 DOI: 10.1155/2012/560493] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Accepted: 03/14/2012] [Indexed: 11/21/2022] Open
Abstract
Counseling patients with DCIS in a rational manner can be extremely difficult when the range of treatment criteria results in diverse and confusing clinical recommendations. Surgeons need tools that quantify measurable prognostic factors to be used in conjunction with clinical experience for the complex decision-making process. Combination of statistically significant tumor recurrence predictors and lesion parameters obtained after initial excision suggests that patients with DCIS can be stratified into specific subsets allowing a scientifically based discussion. The goal is to choose the treatment regimen that will significantly benefit each patient group without subjecting the patients to unnecessary risks. Exploring the effectiveness of complete excision may offer a starting place in a new way of reasoning and conceiving surgical modalities in terms of "downscoring" or "upscoring" patient risk, perhaps changing clinical approach. Reexcison may lower the specific subsets' score and improve local recurrence-free survival also by revealing a larger tumor size, a higher nuclear grade, or an involved margin and so suggesting the best management. It seems, that the key could be identifying significant relapse predictive factors, according to validated risk investigation models, whose value is modifiable by the surgical approach which avails of different diagnostic and therapeutic potentials to be optimal. Certainly DCIS clinical question cannot have a single curative mode due to heterogeneity of pathological lesions and histologic classification.
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Affiliation(s)
- P. Orsaria
- Division of Surgical Oncology, Department of Surgery, Tor Vergata University Hospital, 00133 Rome, Italy
| | - A. V. Granai
- Division of Surgical Oncology, Department of Surgery, Tor Vergata University Hospital, 00133 Rome, Italy
| | - D. Venditti
- Division of Surgical Oncology, Department of Surgery, Tor Vergata University Hospital, 00133 Rome, Italy
| | - G. Petrella
- Division of Surgical Oncology, Department of Surgery, Tor Vergata University Hospital, 00133 Rome, Italy
| | - O. Buonomo
- Division of Surgical Oncology, Department of Surgery, Tor Vergata University Hospital, 00133 Rome, Italy
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Gurdal S, Karanlik H, Cabioglu N, Ozcinar B, Yavuz E, Tuzlali S, Ozmen V. Positive or close margins in breast conserving surgery: Is re-excision always necessary? Eur J Surg Oncol 2012; 38:399-406. [DOI: 10.1016/j.ejso.2012.02.182] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Revised: 02/11/2012] [Accepted: 02/27/2012] [Indexed: 10/28/2022] Open
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24
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Sneed GM, Duncan LD. Quantifying the extent of invasive carcinoma and margin status in partial mastectomy cases having a gross lesion: is a defined tissue processing protocol needed? Am J Clin Pathol 2011; 136:747-53. [PMID: 22031313 DOI: 10.1309/ajcpy4mi1rcwptvr] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
Accurate estimation of disease extent and margin status is critical when evaluating partial mastectomy cases because both are predictors of recurrence. No published standards exist for processing specimens involved by invasive carcinoma, presumably because such cases have a gross lesion. We retrospectively studied 100 partial mastectomy cases and concluded that a standardized tissue mapping protocol is needed to ensure adequate pathologic examination even when a gross lesion is present. When mapped and unmapped findings were compared, 17 cases (10 with ductal and 7 with lobular carcinoma) had an increase in carcinoma size, 12 cases (9 with ductal and 3 with lobular carcinoma) had an increase in pathologic T stage, and positive margins were found in 8 cases (7 with ductal and 1 with lobular carcinoma). We describe our tissue-mapping protocol, and advocate its use as a standardized protocol for processing all partial mastectomy specimens.
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Affiliation(s)
- George M. Sneed
- Department of Pathology, University of Tennessee Graduate School of Medicine, Knoxville
| | - Lisa D. Duncan
- Department of Pathology, University of Tennessee Graduate School of Medicine, Knoxville
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25
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Feron JG, Nguyen A, Bézu C, Antoine M, Darai E, Coutant C, Rouzier R, Uzan S. Interest in cavity shaving in breast conservative treatment does not depend on lumpectomy technique. Breast 2011; 20:358-64. [DOI: 10.1016/j.breast.2011.01.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2009] [Revised: 06/17/2010] [Accepted: 01/19/2011] [Indexed: 11/15/2022] Open
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26
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Groot G, Rees H, Pahwa P, Kanagaratnam S, Kinloch M. Predicting local recurrence following breast-conserving therapy for early stage breast cancer: The significance of a narrow (≤2 mm) surgical resection margin. J Surg Oncol 2011; 103:212-6. [DOI: 10.1002/jso.21826] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Accepted: 11/10/2010] [Indexed: 11/12/2022]
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27
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Patani N, Khaled Y, Al Reefy S, Mokbel K. Ductal carcinoma in-situ: an update for clinical practice. Surg Oncol 2010; 20:e23-31. [PMID: 21106367 DOI: 10.1016/j.suronc.2010.08.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Revised: 07/30/2010] [Accepted: 08/30/2010] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Ductal carcinoma in-situ (DCIS) is a heterogeneous entity with an elusive natural history. The objective of radiological, histological and molecular characterisation remains to reliably predict the biological behaviour and optimise clinical management strategies. Increases in diagnostic frequency have followed the introduction of mammographic screening and increased utility of magnetic resonance imaging. However, progress remains limited in distinguishing non-progressive incidental lesions from their progressive and clinically relevant counterparts. This article reviews current management strategies for DCIS in the context of recent randomized trials, including the role of sentinel lymph node biopsy (SLNB), adjuvant radiotherapy (RT) and endocrine treatment. METHODS Literature review facilitated by Medline, PubMed, Embase and Cochrane databases. RESULTS DCIS should be managed in the context of a multidisciplinary team. Local control depends upon adequate surgical clearance with margins of at least 2 mm. SLNB is not routinely indicated and should be reserved for those with concurrent or recurrent invasive disease. SLNB can be considered in patients undergoing mastectomy (MX) and those with risk factors for invasion such as palpability, comedo morphology, necrosis or recurrent disease. RT following BCS significantly reduces local recurrence (LR), particularly in those at high-risk. There remains a lack of level-1 evidence supporting the omission of adjuvant RT in selected low-risk cases. Large, multi-centric or recurrent lesions (particularly in cases of prior RT) should be treated by MX with the opportunity for immediate reconstruction. Adjuvant Tamoxifen may reduce the risk of LR in selected cases with hormone sensitive disease. CONCLUSION Further research is required to determine the role of contemporary RT regimes and endocrine therapies. Biological profiling and molecular analysis represent an opportunity to improve our understanding of the tumour biology of this condition and rationalise its treatment. Reliable identification of low-risk lesions could allow treatment to be less radical or safely omitted.
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Affiliation(s)
- Neill Patani
- The London Breast Institute, The Princess Grace Hospital, London, UK
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28
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Melstrom LG, Melstrom KA, Wang EC, Pilewskie M, Winchester DJ. Ductal carcinoma in situ: size and resection volume predict margin status. Am J Clin Oncol 2010; 33:438-42. [PMID: 20023569 DOI: 10.1097/coc.0b013e3181b9cf31] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES There is strong evidence that breast conservation surgery (BCS) with negative margins for ductal carcinoma in situ (DCIS) is associated with low rates of recurrence. Our goal was to identify factors associated with positive margins in BCS for DCIS. METHODS A retrospective database review identified 823 patients diagnosed with DCIS. The current analysis included 546 of those patients treated with BCS from 2000 to 2006 with complete data regarding tumor and lumpectomy dimensions. Variables analyzed included tumor size, lumpectomy volume, estrogen and progesterone receptor status, histologic subtype, grade, and age at diagnosis. χ analysis and t tests were used to identify factors that may predict positive margins. A multivariate regression model was developed to determine independent variables predictive of positive margin status. RESULTS A total of 33% of specimens had positive margins. Lumpectomy volume, tumor size, nuclear grade (low vs. high), and number of slides positive for DCIS were all significant for positive margin status by bivariate analysis. On multivariate analysis, tumor size (P < 0.001; odds ratio, 2.37; 95% confidence interval, 1.712, 3.296) and resection volume (P = 0.0006; odds ratio, 0.48; 95% confidence interval, 0.318, 0.729) remained significantly associated with positive margin status. Age at diagnosis, histologic subtype, tumor grade, and estrogen and progesterone status all were not associated with margin status. CONCLUSIONS Positive margins after BCS for DCIS are associated with larger lesions and a smaller volume of resection. With 33% of patients having positive margins, these data suggest that a more aggressive initial resection may avoid positive margins and thus lower the risk of recurrence or the need for additional surgery.
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Affiliation(s)
- Laleh G Melstrom
- Department of Surgery, Northwestern University, Chicago, IL, USA
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29
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Estévez LG, Álvarez I, Seguí MÁ, Muñoz M, Margelí M, Miró C, Rubio C, Lluch A, Tusquets I. Current perspectives of treatment of ductal carcinoma in situ. Cancer Treat Rev 2010; 36:507-17. [DOI: 10.1016/j.ctrv.2010.03.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2009] [Revised: 03/15/2010] [Accepted: 03/21/2010] [Indexed: 11/16/2022]
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30
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Ductal carcinoma in situ (DCIS): pathological features, differential diagnosis, prognostic factors and specimen evaluation. Mod Pathol 2010; 23 Suppl 2:S8-13. [PMID: 20436505 DOI: 10.1038/modpathol.2010.40] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Ductal carcinoma in situ (DCIS) is a heterogeneous, unicentric precursor of invasive breast cancer, which is frequently identified through mammographic breast screening programs. The lesion can cause particular difficulties for specimen handling in the laboratory and typically requires even more diligent macroscopic assessment and sampling than invasive disease. Pitfalls and tips for macroscopic handling, microscopic diagnosis and assessment, including determination of prognostic factors, such as cytonuclear grade, presence or absence of necrosis, size of the lesion and distance to margins are described. All should be routinely included in histopathology reports of this disease; in order not to omit these clinically relevant details, synoptic reports, such as that produced by the College of American Pathologists are recommended. No biomarkers have been convincingly shown, and validated, to predict the behavior of DCIS till date.
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31
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The Influence of Margin Width and Volume of Disease Near Margin on Benefit of Radiation Therapy for Women With DCIS Treated With Breast-Conserving Therapy. Ann Surg 2010; 251:583-91. [DOI: 10.1097/sla.0b013e3181b5931e] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
BACKGROUND Breast conservation therapy (BCT) has become the standard of treatment for early stage breast cancer, and the surgical margin was one of the important factors that affected risk of local recurrence. This review looks at the safe margin for BCT in early stage invasive breast cancer and ductal carcinoma in situ (DCIS). METHODS Published literature abstracted in Medline was searched using the gateway site from the US National Library of Medicine. CONCLUSIONS A positive margin is associated with increased risk of local recurrence after BCT for invasive breast cancer and DCIS. However there was no cut off for the margin width and the significance of a close margin remains controversial. It was generally accepted that the risk of local recurrence was low if the margin was >or=10 mm while margins that were <2 mm were considered inadequate. The surgeon needs to balance the risk between local recurrence and cosmesis in planning BCT so that the prognosis is not compromised.
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33
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Kim JS, Moon HG, Ahn SK, Min JW, Shin HC, Kim HS, Yeom CK, Ha SH, Chie EK, Han W, Noh DY. Clinicopathological Characteristics and Factors Affecting Recurrence of Ductal CarcinomaIn Situin Korean Women. J Breast Cancer 2010. [DOI: 10.4048/jbc.2010.13.4.392] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Ji Sun Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyeong-Gon Moon
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Soo Kyung Ahn
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jun Won Min
- Department of Surgery, Dankook University College of Medicine, Cheonan, Korea
| | - Hee Chul Shin
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Han Suk Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Cha Kyung Yeom
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sung Hwan Ha
- Department of Radiation Oncolocy, Seoul National University College of Medicine, Seoul, Korea
| | - Eui Kyu Chie
- Department of Radiation Oncolocy, Seoul National University College of Medicine, Seoul, Korea
| | - Wonshik Han
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Young Noh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Ductal Carcinoma In Situ of the Breast With Close or Focally Involved Margins Following Breast-Conserving Surgery: Treatment With Reexcision or Radiotherapy With Increased Dosage. Int J Radiat Oncol Biol Phys 2009; 75:1021-8. [DOI: 10.1016/j.ijrobp.2008.12.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2008] [Revised: 11/29/2008] [Accepted: 12/02/2008] [Indexed: 10/20/2022]
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35
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Fadare O, Clement NF, Ghofrani M. High and intermediate grade ductal carcinoma in-situ of the breast: a comparison of pathologic features in core biopsies and excisions and an evaluation of core biopsy features that may predict a close or positive margin in the excision. Diagn Pathol 2009; 4:26. [PMID: 19691836 PMCID: PMC2740842 DOI: 10.1186/1746-1596-4-26] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2009] [Accepted: 08/19/2009] [Indexed: 11/10/2022] Open
Abstract
Low and high-grade ductal carcinoma in-situ (DCIS) are known to be highly disparate by a multitude of parameters, including progression potential, immunophenotype, gene expression profile and DNA ploidy. In this study, we analyzed a group of intermediate and high-grade DCIS cases to determine how well the core biopsy predicts the maximal pathology in the associated excisions, and to determine if there are any core biopsy morphologic features that may predict a close (≤ 0.2 cm) or positive margin in the subsequent excision. Forty-nine consecutive paired specimens [core biopsies with a maximal diagnosis of DCIS, and their corresponding excisions, which included 20 and 29 specimens from mastectomies and breast conserving surgeries respectively] were evaluated in detail. In 5 (10%) of 49 cases, no residual carcinoma was found in the excision. In another 4 cases, the changes were diagnostic only of atypical ductal hyperplasia. There were 4 and 3 respective cases of invasive and microinvasive carcinoma out of the 49 excision specimens, for an overall invasion frequency of 14%. In 28 cases where a sentinel lymph node evaluation was performed, only 1 was found to be positive. Among the 40 cases with at least residual DCIS in the excision, there were 5 cases in which comedo-pattern DCIS was present in the excision but not in the core biopsy, attributed to the lower maximal nuclear grade in the biopsy proliferation in 4 cases and the absence of central necrosis in the 5th. For the other main histologic patterns, in 8 (20%) of 40 cases, there were more patterns identified in the core biopsy than in the corresponding excision. For the other 32 cases, 100%, 66%, 50%, 33% and 25% of the number of histologic patterns in the excisions were captured in 35%, 5%, 17.5%, 15% and 7.5% of the preceding core biopsies respectively. Therefore, the core biopsy reflected at least half of the non-comedo histologic patterns in 77.5% of cases. In 6(15%) of the 40 cases, the maximum nuclear grade of the excision (grade 3) was higher than that seen in the core biopsy (grade 2). Overall, however, the maximum nuclear grade in the excision was significantly predicted by maximum nuclear grade in the core biopsy (p = 0.028), with a Phi of 0.347, indicating a moderately strong association. At a size threshold of 2.7 cm, there was no significant association between lesional size and core biopsy features. Furthermore, the clear margin width of the cases with lesional size ≤ 2.7 cm (mean 0.69 cm) was not significantly different (p = 0.4) from the cases with lesional size > 2.7 cm (mean 0.56 cm). Finally, among a variety of core biopsy features that were evaluated, including maximum nuclear grade, necrosis, cancerization of lobules, number of tissue cores with DCIS, number of DCIS ducts per tissue core, total DCIS ducts, or comedo-pattern, only necrosis was significantly associated with a positive or close (≤ 0.2 cm) margin on multivariate analysis (Phi of 0.350). It is concluded that a significant change [to invasive disease (14%) or to no residual disease (10%)] is seen in approximately 24% of excisions that follow a core biopsy diagnosis of intermediate or high-grade DCIS. Core biopsy features are of limited value in predicting a close or positive margin in these lesions.
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Affiliation(s)
- Oluwole Fadare
- Department of Pathology, Wilford Hall Medical Center, Lackland Air Force Base, San Antonio, Texas, USA.
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36
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Actual management of ductal carcinoma in situ of the breast. Arch Gynecol Obstet 2009; 280:699-705. [DOI: 10.1007/s00404-009-0999-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2008] [Accepted: 02/09/2009] [Indexed: 11/26/2022]
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37
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The surgical margin status after breast-conserving surgery: discussion of an open issue. Breast Cancer Res Treat 2009; 113:397-402. [PMID: 18386174 DOI: 10.1007/s10549-008-9929-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Hypothesis The best therapeutic approach to the involved or proximal surgical margins has not been defined yet; surgical margins status can influence the local relapse of disease in breast carcinoma, but the impact on overall survival has not been clearly demonstrated. Purpose of this work is to find in the available literature further evidence to guide the therapeutic behaviour in patients with close margins by invasive carcinoma. Design Review of the currently available literature on the evaluation of surgical margins in breast conserving surgery; influence of margin involvement by invasive component or intraductal component. Patients or other participants Literature research by PubMed on the topics of breast carcinoma, conservative surgery and margin definition and status; therapeutic approach to involved margins. Main outcome measure We reviewed the available literature focusing our attention to the definition of clear surgical margins and to the value of the close proximity of margins in relation to the local control of disease and the best therapeutic management of different situations. Results Further evidence is needed on large numbers of patients to understand how to evaluate surgical margins in invasive breast carcinoma. Conclusions There is no consensus on the definition of "clear surgical margins", and the ideal approach to the close proximity of margins has not been defined. It is not sure whether a new surgical procedure is really needed in every case of close proximity of tumor cells to the margins. Radiation therapy could be a good option in the management of these cases, but further evidence is needed to establish the real impact of clear surgical margins on local control of disease and, furthermore, on survival.
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38
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Lester SC, Bose S, Chen YY, Connolly JL, de Baca ME, Fitzgibbons PL, Hayes DF, Kleer C, O'Malley FP, Page DL, Smith BL, Weaver DL, Winer E. Protocol for the examination of specimens from patients with ductal carcinoma in situ of the breast. Arch Pathol Lab Med 2009; 133:15-25. [PMID: 19123730 DOI: 10.5858/133.1.15] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2008] [Indexed: 11/06/2022]
Affiliation(s)
- Susan C Lester
- Department of Pathology, Brigham and Women's Hospital, Boston, MA 02115, USA.
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Grin A, Horne G, Ennis M, O'Malley FP. Measuring extent of ductal carcinoma in situ in breast excision specimens: a comparison of 4 methods. Arch Pathol Lab Med 2009; 133:31-7. [PMID: 19123733 DOI: 10.5858/133.1.31] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2008] [Indexed: 11/06/2022]
Abstract
CONTEXT Measuring the extent of nonpalpable ductal carcinoma in situ (DCIS) in a breast specimen is challenging but important because it influences patient management. There is no standardized method for estimating the extent of DCIS, although serial sequential sampling with mammographic correlation is considered an accurate method. OBJECTIVE To estimate the extent of DCIS using various methods and to compare these estimations with the extent as determined by the serial sequential sampling method. DESIGN A total of 78 primary breast excisions with DCIS were retrospectively reviewed. All specimens had been sampled using the serial sequential sampling method, which involved mapping the location of each block on the sliced specimen radiograph and calculating the extent through 3-dimensional reconstruction. The other measures for estimating extent included (1) calculating size based on areas of calcification, (2) recording the number of blocks involved by DCIS and multiplying that number by 0.3 cm, and (3) measuring the largest extent of DCIS on a single slide. RESULTS All 3 alternative methods tended to underestimate the DCIS. Discrepancies became more pronounced as size increased. The percentage of cases estimated to within 1 cm of the serial sequential sampling method were 81%, 72%, and 50%, respectively, for the calcification, blocks, and single-slide methods; differences of more than 2 cm were seen in 9%, 8%, and 30% of cases, respectively. CONCLUSIONS The single-slide method performed poorly and should be used only when DCIS is limited to a single slide. Although the calcification and the blocks methods gave better estimates, both produced substantial underestimates and/or overestimates that could affect clinical decision making.
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Affiliation(s)
- Andrea Grin
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Ontario, Canada
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40
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Mountford C, Ramadan S, Stanwell P, Malycha P. Proton MRS of the breast in the clinical setting. NMR IN BIOMEDICINE 2009; 22:54-64. [PMID: 19086012 DOI: 10.1002/nbm.1301] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Information for determining whether a primary breast lesion is invasive and its receptor status and grade can be obtained before surgery by performing proton MRS on a fine-needle aspiration biopsy (FNAB) specimen and analyzing the MRS information by a pattern recognition method. Two-dimensional MRS, on either specimens or cells, allows the unambiguous assignment of most resonances. When correlated with the spectral regions selected by the pattern recognition method, there are strong indications for the biochemical markers responsible for prognostic information of invasive capacity and metastatic spread. Spectral assignments and biological correlations can be made using cell models. In vivo MRS can distinguish invasive from benign lesions. This pathological distinction can be made from the presence of resonances at discrete frequencies. To achieve this level of spectral resolution and signal-to-noise ratio, there are stringent requirements when acquiring and processing the data. The challenge now is to implement two-dimensional MRS in vivo. Until this is realized, the combination of in vivo MR, for diagnosis and spatial location, and MRS, for image-guided biopsy to provide information on tumor spread, promises to provide a higher level of preoperative diagnosis than previously achieved.
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Affiliation(s)
- Carolyn Mountford
- Centre for Clinical Spectroscopy, Department of Radiology, Brigham & Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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41
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Tucker FL. New Era Pathologic Techniques in the Diagnosis and Reporting of Breast Cancers. ACTA ACUST UNITED AC 2008. [DOI: 10.1053/j.sembd.2009.04.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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42
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Outcomes of Multiple Wire Localization for Larger Breast Cancers: When Can Mastectomy Be Avoided? J Am Coll Surg 2008; 207:342-6. [DOI: 10.1016/j.jamcollsurg.2008.04.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2008] [Revised: 04/10/2008] [Accepted: 04/14/2008] [Indexed: 11/20/2022]
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43
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Zavagno G, Goldin E, Mencarelli R, Capitanio G, Bianco PD, Marconato R, Mocellin S, Marconato G, Belardinelli V, Marcon F, Nitti D. Role of resection margins in patients treated with breast conservation surgery. Cancer 2008; 112:1923-31. [DOI: 10.1002/cncr.23383] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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44
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O’Donnell M, Salem A, Badger S, Sharif M, Lioe T, Spence R. Completion mastectomy after breast conserving surgery. Breast 2008; 17:199-204. [DOI: 10.1016/j.breast.2007.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2007] [Revised: 09/12/2007] [Accepted: 10/08/2007] [Indexed: 11/26/2022] Open
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45
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Arora S, Menes TS, Moung C, Nagi C, Bleiweiss I, Jaffer S. Atypical ductal hyperplasia at margin of breast biopsy--is re-excision indicated? Ann Surg Oncol 2007; 15:843-7. [PMID: 17987337 DOI: 10.1245/s10434-007-9681-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2007] [Revised: 10/03/2007] [Accepted: 10/05/2007] [Indexed: 11/18/2022]
Abstract
BACKGROUND Atypical duct hyperplasia (ADH) observed during core needle biopsy is associated with a high rate of cancer upon excision. Controversy exists regarding the need to re-excise ADH involving a margin. The purpose of this study was to determine the rate of residual pathology in patients that underwent re-excision for ADH involving the margin. METHODS In a retrospective review of the pathology database from 1 January 2000 to 1 June 2006, we identified 44 lumpectomy specimens with ADH involving the margin; 24 patients (55%) had a re-excision. Slides were reviewed to verify the diagnosis of ADH near the margin and the presence of residual disease on re-excision associated with the biopsy cavity. RESULTS Patients had pure ADH (15, 63%), ADH and ductal carcinoma in situ (DCIS) (7, 29%) or ADH with invasive carcinoma (2, 8%). Residual ADH or cancer was found in 14 of 24 patients (58%). Of 15 patients with pure ADH, 6 (40%) had residual pathology: ADH (2), DCIS (2) and invasive carcinoma (2). In this group, 27% of patients were reassessed as having DCIS or invasive carcinoma. Of the 9 patients with cancer, 8 (89%) had residual disease in the form of ADH (4) or DCIS (4). CONCLUSIONS ADH found at the margin of a lumpectomy specimen is associated with a high rate of residual ADH and cancer. Over one quarter of the patients with an initial diagnosis of ADH were reassessed as having DCIS or invasive carcinoma. Re-excision in all patients with ADH involving the margin is recommended.
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Affiliation(s)
- Shalini Arora
- Department of Surgery, Mount Sinai Medical Center, New York, NY, USA
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Schouten van der Velden AP, van Vugt R, Van Dijck JAAM, Leer JWH, Wobbes T. Local Recurrences After Different Treatment Strategies for Ductal Carcinoma In Situ of the Breast: A Population-Based Study in the East Netherlands. Int J Radiat Oncol Biol Phys 2007; 69:703-10. [PMID: 17544591 DOI: 10.1016/j.ijrobp.2007.03.062] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2007] [Revised: 03/29/2007] [Accepted: 03/31/2007] [Indexed: 10/23/2022]
Abstract
PURPOSE Outcomes after different treatment strategies for ductal carcinoma in situ (DCIS) of the breast were analyzed for a geographically defined population in the East Netherlands. METHODS AND MATERIALS A total of 798 patients with a first diagnosis of DCIS between January 1989 and December 2003 were included and their medical records were reviewed. Survival rates for ipsilateral recurrences were calculated by the Kaplan-Meier method and a multivariate Cox proportional hazards regression model was used to evaluate the prognostic significance of different variables. RESULTS The 5-year recurrence-free survival was 75% for breast conserving surgery (BCS) alone (237 patients) compared with 91% for BCS followed by radiation therapy (RT; 153 patients) and 99% for mastectomy (408 patients, p < 0.01). Independent risk factors for local recurrences were treatment strategy, symptomatically detected DCIS, and presence of comedo necrosis. Margin status reached statistical significance only for patients treated by BCS (hazard ratio, 2.0; 95% confidence interval, 1.1-4.0) whereas significance of other prognostic variables did not change. CONCLUSIONS In a defined population outside a trial setting, RT after BCS for DCIS lowered recurrence rates. Besides the use of RT, a microscopically complete excision of DCIS is essential. This is especially true for patients with symptomatically detected DCIS and with tumors that contain comedo necrosis, as these groups are at particular high risk for recurrent disease.
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McLaughlin SA, Ochoa-Frongia LM, Patil SM, Cody HS, Sclafani LM. Influence of frozen-section analysis of sentinel lymph node and lumpectomy margin status on reoperation rates in patients undergoing breast-conservation therapy. J Am Coll Surg 2007; 206:76-82. [PMID: 18155571 DOI: 10.1016/j.jamcollsurg.2007.07.021] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2007] [Revised: 06/29/2007] [Accepted: 07/18/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Frozen-section analysis (FS) of the sentinel lymph node (SLN) is performed to avoid reoperation for axillary lymph node dissection (ALND), but it can miss micrometastatic disease, is labor intensive for the pathologist, and does not alter the number of breast-conservation therapy (BCT) patients needing reoperation for positive margins. The purpose of this study was to determine if eliminating FS would change reoperation rates in BCT patients. STUDY DESIGN Between January 2004 and December 2005, 1,218 patients had simultaneous BCT and SLN biopsy for invasive breast cancer. FS of the SLN was used selectively at the surgeon's discretion. Clinical and pathologic data were collected. RESULTS Overall, 542 of 1,218 (44%) patients had positive margins. FS of the SLN was performed in 931 of 1,218 (76%) patients. In those having FS, the SLN positivity rate was 33% (306 of 931). FS identified the positive SLN in 170 of 306 (56%) patients with positive nodes, allowing for immediate ALND. But 101 of these 170 patients had positive lumpectomy margins; and FS of the SLN saved 69 of 931 (7%) patients a second operation. Of patients not having FS, 48 of 287 (17%) had a positive SLN on final pathology. Only 18 of 48 (those seen on routine hematoxylin and eosin) might have been seen on FS, potentially sparing reoperation. Half of patients not having FS required reexcision for positive margins. FS would have spared reoperation for only 8 of 287 (3%) patients in this group. Overall, of 354 of 1,218 patients with SLN metastases, 170 had immediate ALND and 98 had delayed ALND. Of those having delayed ALND, 68 of 98 also had positive margins. CONCLUSIONS Among patients having BCT with SLN biopsy, FS identified the positive SLN in 56% of patients with positive SLNs, allowing immediate ALND, and was false negative in 44%. Margin status remains a frequent indication for reoperation in BCT; routine FS analysis of the SLN ultimately saves only a minority of patients a second operation.
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Affiliation(s)
- Sarah A McLaughlin
- Department of Breast Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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Patani N, Cutuli B, Mokbel K. Current management of DCIS: a review. Breast Cancer Res Treat 2007; 111:1-10. [PMID: 17902049 DOI: 10.1007/s10549-007-9760-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2007] [Accepted: 09/10/2007] [Indexed: 11/28/2022]
Abstract
Ductal carcinoma in-situ (DCIS) is a heterogeneous disease, in terms of its radiological characteristics, histological morphology and molecular attributes. This diversity is reflected in its natural history and influences optimal treatment strategy. A significant proportion of DCIS lesions behave in a clinically benign fashion and do not progress to invasive disease. Reliable identification of these patients could allow treatment to be less radical or safely omitted. Management should be tailored to the individual within the context of a multidisciplinary team. Approaches such as biological profiling and molecular analysis represent an opportunity to improve our understanding of the tumour biology of this condition and rationalise its treatment. This article reviews the management strategies for DCIS in the context of recent randomized trials, including the role of sentinel lymph node biopsy, adjuvant radiotherapy and tamoxifen.
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Affiliation(s)
- Neill Patani
- The London Breast Institute, The Princess Grace Hospital, 45 Nottingham Place, London, W1U 5NY, UK.
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Abstract
This article summarizes the modern evidence-based management of ductal carcinoma in situ. The data addressing the surgical issues, including indications for mastectomy and the use of sentinel node biopsy, are presented. The randomized trials examining the role of radiation therapy after breast-conserving surgery and the use of tamoxifen in ductal carcinoma in situ are discussed. Factors to consider in developing a management strategy for the individual patient are elucidated in the final section.
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Affiliation(s)
- Martin J O'Sullivan
- Department of Surgical Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111-2497, USA
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Abstract
Since clinical trials have demonstrated that breast conservation is safe and effective for treatment of invasive breast cancer, there has been considerable disagreement and controversy about what constitutes an acceptable margin in breast cancer. Dogmatic adherence to a set margin for all patients may cause a higher mastectomy rate than necessary, and thus it is important to understand how various clinical and pathologic factors affect local recurrence and outcome. This review discusses that controversy, as well as what factors should be considered when evaluating patients on an individual basis.
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