Local control in ductal carcinoma in situ treated by excision alone: incremental benefit of larger margins

BACKGROUND: Margin width has been shown previously to be the most important predictor of local treatment failure after breast conservation for ductal carcinoma in situ (DCIS). METHODS: Five variables thought to be associated with local recurrence were evaluated by univariate and multivariate analysis in 455 nonrandomized patients with DCIS treated with excision alone. RESULTS: Multivariate analysis showed that margin width, age, nuclear grade, and tumor size all were independent predictors of local recurrence, with margin width as the single most important predictor. After adjusting for all other predictors the likelihood of local recurrence for patients with margins less than 10 mm was 5.39 times as much as that for patients with margins of 10 mm or more (95% confidence interval, 2.68-10.64). CONCLUSIONS: Margin width, the distance between DCIS and the closest inked margin, was the single most important predictor of local recurrence. As margin width increases, the risk for local recurrence decreases.     

Evaluation of margin status in lumpectomy specimens and residual breast carcinoma

Residual disease leads to most local recurrences, especially in those patients treated with breast-conserving therapy (BCT). This study evaluates whether assessment of excisional biopsy margins accurately predicts the presence or absence of residual tumor in the lumpectomy bed. The margin status of 201 consecutive lumpectomy specimens of 178 infiltrating and 23 in situ breast carcinomas followed by reexcision were evaluated microscopically and classified as "positive" (tumor at the inked margins), "negative" (tumor more than 0.1 cm from the inked margins), "close" (tumor within 0.1 cm of the inked margins, but not transecting it), and "indeterminate" (biopsy not inked or fragmented). Tumor size and grade were also analyzed, as potential predictors for residual disease. Residual tumor was found in 41% of the patients: in 21% of the cases with negative margins, in 63% with positive margins, in 30% with close margins, and in 56% with indeterminate margins. In 37% of the positive and 70% of the close margin cases, no tumor was found in reexcised specimens. In 24% of the cases the residual disease was composed entirely of an in situ component of the same histologic type as the initial biopsy. No relationship was found between tumor size or grade and residual disease. For breast tumors, histologically negative and "close" biopsy margins do not guarantee complete excision. A number of factors seem to be responsible for the discrepancy between the margin status and the presence/absence of residual cancer in the lumpectomy bed.     

Breast-Conserving Therapy for Ductal Carcinoma in Situ: The Van Nuys Experience with Excision Plus Radiation Therapy

Abstract: The incidence of ductal carcinoma in situ (DCIS) of the breast has increased significantly in the last 15 years paralleling increases in the use of screening mammography. During that time, breast-conserving therapy for DCIS has become an established treatment option for patients with DCIS. 185 patients with pure DCIS treated with excision and radiation therapy were studied. The risk of local recurrence increased as nuclear grade or the diameter of the primary tumor increased. It decreased as margin width increased. Tumors containing predominantly comedo histology had an increased local recurrence rate when compared with noncomedo lesions. There was no difference in local recurrence rates for patients treated 4 or 5 days per week. The median time to local recurrence was 53 months. At 12 years, the actuarial local recurrence rate was 24% for all patients. The breast-cancer specific mortality over the same 12 year period was 3%. The increasing incidence of DCIS necessitates that current treatment options undergo continuous re-evaluation. Although it is likely that selected subsets of low-risk patients can be adequately treated with excision and observation, it is equally likely that patients at high risk for local recurrence will require radiation therapy as part of their management if breast preservation is chosen. Our data suggests that histologic factors such as large tumor size, narrow margin width, high nuclear grade, and comedo architecture may aid in selecting which patients require the addition of radiation therapy to their treatment regimen and which patients do not if breast preservation is chosen.     

Separate cavity margin sampling at the time of initial breast lumpectomy significantly reduces the need for reexcisions

In breast conservation therapy, the margin status of the specimen predicts local recurrence and determines the need for reexcision. Many surgeons now take, at the time of lumpectomy, multiple separate "cavity margins" (CM) (the entire wall of the residual cavity) as final margins that supersede the oriented lumpectomy margins (LMs). We studied the efficacy of this method in 126 patients (23 with ductal carcinoma in situ [DCIS] only and 103 with invasive carcinoma with or without DCIS) who had an oriented lumpectomy specimen and also had four to six additional CMs. The tumors were evaluated for the following: size, grade, LM status (distance of tumor from margin and, if involved, extent of involvement), vascular invasion, lymph node status, and presence or absence of extensive intraductal component. The additional CM specimens were evaluated for residual carcinoma (if any) and its distance from the inked true margins, and the results were correlated with the corresponding LMs. Only approximately 50% of patients (52 of 103) with histologically positive LMs (defined as carcinoma within 2 mm of the inked surface) had residual carcinoma in their CMs. Additional CM sampling rendered the overall final margin status histologically negative in 61 of 103 (59%) cases with histologically positive LMs, therefore significantly reducing the need for reexcision. Younger patient age, higher number of positive LMs, high tumor grade, and the presence of extensive intraductal component were predictive of residual carcinoma in CM specimens, whereas the distance of carcinoma from the inked surface and the extent of tumor involvement of histologically positive LMs were not. Because CM specimens taken from patients with histologically positive LMs usually lack tumor, we suspect that many positive LMs are likely false positives. Possible factors accounting for false-positive LMs include seepage of ink into crevices of the specimen promoted by excessive inking, tumor friability promoting displacement of tumor into ink, manipulation of specimens for radiographs, and retraction artifact.     

Breast-conserving therapy for primary Ductal Carcinoma in Situ in The Netherlands: A multi-center study and population-based analysis

ObjectiveThe aim of this study was to analyse the efficacy of breast-conserving therapy (BCT) for women with primary DCIS in a population-based setting.MethodsData were used from five Radiotherapy centres in The Netherlands from 2000 to 2010, all treated with BCT. Of all the cases, 59.2% received a boost of radiotherapy after their whole breast irradiation (WBI), irrespective of margin status.ResultsA total of 1248 cases with primary DCIS were analysed. The 10-years LRFS was 92.9%. Age ≤50 years and a positive margin were significantly related to local relapse free survival (LRFS). Having a boost had no impact on LRFS, showing a nearly equal recurrence pattern in patients with and without a boost. Separate analyses were done on patients who had received and not received a boost of radiotherapy after WBI. We noted 9.1% contra-lateral breast tumours. The 10-years disease specific survival (DSS) rate was 99.0%.ConclusionsDCIS of the breast and treated with BCT results in excellent LRFS and DSS. Primary surgical lumpectomy with negative margins followed by WBI seems to be the treatment of choice in DCIS treated with BCS with respect to IBTR.     

Local failure and margin status in early-stage breast carcinoma treated with conservation surgery and radiation therapy.

OBJECTIVE: The authors determined whether microscopically positive surgical margins are detrimental to the outcome of early stage breast cancer patients treated with conservation surgery and radiation therapy. SUMMARY BACKGROUND DATA: The optimal extent of breast surgery required for patients treated with conservation surgery and radiation therapy has not been established. To achieve breast preservation with good cosmesis, it is desirable to resect as little normal tissue as possible. However, it is critical that the resection does not leave behind a tumor burden that cannot be adequately managed by moderate doses of radiation. It is not known whether microscopically positive surgical margins are detrimental to patient outcome. METHODS: The records of 259 consecutive women (262 breasts) treated with local excision (complete removal of gross tumor with a margin) and axillary dissection followed by radiation therapy for clinical stage I and II infiltrating ductal breast cancer at Duke University Medical Center and the University of North Carolina between 1983 and 1988 were reviewed. Surgical margins were considered positive if tumor extended to the inked margins; otherwise the margins were considered negative. Margins that could not be determined, either because the original pathology report did not comment on margins, or because the original specimen had not been inked were called indeterminate. RESULTS: Of the 262 tumors, 32 (12%) had positive margins, 132 (50%) had negative margins, and the remaining 98 (38%) had indeterminate margins. There were 11 (4%) local failures; 3/32 (9%) from the positive margin group, 2/132 (1.5%) from the negative margin group, and 6/98 (6%) from the indeterminate group. The actuarial local failure rates at 5 years were 10%, 2%, and 10%, respectively, p = 0.014 positive vs. negative, p = 0.08 positive vs. indeterminate (log rank test). Margin status had no impact on survival or freedom from distant metastasis; 63 patients who originally had positive or indeterminate margins were re-excised. Two of 7 with positive margins after re-excision versus 1/56 rendered margin negative had a local recurrence. CONCLUSIONS: The authors recommend re-excision for patients with positive margins because of improved local control of those rendered margin negative and identification of those patients at high risk for local failure (those who remain positive after re-excision). Because margin status impacts on local control, tumor margins after conservation surgery should be accurately determined in all patients.     

Breast-conserving therapy for ductal carcinoma in situ: a 20-year experience with excision plus radiation therapy

BACKGROUND: Breast conservation therapy is a practical alternative to mastectomy for the treatment of ductal carcinoma in situ (DCIS). The role of radiation therapy after excision for DCIS has been debated, however, its value in reducing recurrence has been proven by multiple prospective randomized trials and is well accepted. METHODS: We examined a prospective database of 260 patients treated for DCIS with excision and radiation from 1979 to 2002. Two different treatment regimens were examined for local recurrence-free survival. Patients treated with radiation therapy 4 days per week were compared with patients treated 5 days per week. The total doses were similar for both groups; boost types differed. Local recurrence as a function of other factors, including nuclear grade, comedonecrosis, and margin width was evaluated. RESULTS: The median time to local recurrence was 61 months for patients treated 4 days per week compared with 52 months for patients treated 5 days per week (P = not significant). There was no statistical difference in the Kaplan-Meier detailing the probability of local recurrence-free survival for patients treated 4 days per week versus patients treated 5 days per week. Overall, cosmetic results between the two groups were equivalent. CONCLUSIONS: The comparison of two different radiation treatment regimens shows no difference in local disease-free survival or cosmetic result.     

The Results of Conservative Surgery and Radiation for Mammographically Detected Ductal Carcinoma In Situ

Abstract: Approximately 85% of all ductal carcinoma in situ (DCIS) are now detected by mammographic screening. For the most part, the literature that reported the results of conservative surgery and radiation for DCIS reflected outcomes in a heterogeneous patient population that frequently included patients with clinically evident DCIS (palpable mass or bloody nipple discharge). There are limited data regarding outcome in patients with mammographically detected DCIS treated with conservative surgery and radiation. The 10-year breast recurrence rate ranges from 4% to 7% for patients with negative margins of resection with a 10-year cause-specific survival of 96–100%. Factors that have been associated with an increased risk of breast recurrence include the failure to remove all malignant appearing calcifications prior to radiation and positive margins of resection. The influence of young age and positive family history on breast recurrence rates requires further study. To date there has been little correlation with the pathologic features of DCIS (architectural pattern, necrosis, nuclear grade) and breast recurrence rates in patients receiving radiation. Comedo or high nuclear grade DCIS tends to recur at a shorter median interval than noncomedo or low nuclear grade DCIS. Approximately 50% of the recurrences are invasive and salvage mastectomy has resulted in long-term control in 100% of the noninvasive recurrences and approximately 80% of the invasive recurrences.     

Small size ductal carcinoma in situ of the breast: predictors of positive margins after local excision

One of the most important predictors of local recurrence after local excision of ductal carcinoma in situ (DCIS) is margin status. The aim was to study the association between margin status and clinical, radiological, and pathological characteristics and to determine predictors of positive margins after local excision of small size (< or = 4 cm) DCIS. Data were tested for differences regarding margin status, and logistic regression was used to determine predictors of margin status. The population consisted of 105 cases. Overall, 51 cases (49%) had free margins and 54 cases (51%) had positive margins. Positive margins were more often associated with a mean mammographic tumor size of 2.1 cm (P = 0.044) and absence of fine granular calcifications (P = 0.004). Also, high-grade (P = 0.013) and a mean pathological size of 3.2 cm (P < 0.001) were associated with positive margins. The only independent predictor of margin status was pathological grade (P = 0.010).     

Cytologic evaluation of lumpectomy margins in patients with ductal carcinoma in situ: Clinical outcome

Backround: Breast conservation therapy is controversial for ductal carcinoma in situ (DCIS) due to recently reported high recurrence rates. We believe that cytologic evaluation of lumpectomy margins improves efficiency and leads to a lower recurrence rate following lumpectomy for DCIS. Methods: A prospectively accrued database of 1255 breast cancer patients at the H. Lee Moffitt Cancer Center and Research Institute was found to have 218 patients with DCIS (17.4%). Of those 218 cases, 114 were treated with lumpectomy, axillary dissection, and radiation therapy; the remaining 104 patients were treated with mastectomy with or without reconstruction. Imprint cytology was used to evaluate all lumpectomy margins. Permanent sections and imprint cytology were reviewed by the same pathologist. Results: All lumpectomy specimens (116 tumors in 114 patients) were evaluated. The median follow up was 57.5 months (range 2–110 months). One hundred and three patients with 104 tumors were selected on the basis of pure DCIS (with or without microinvasion), and treated with lumpectomy, axillary dissection and radiation therapy. Of the 104 tumors utilizing attempted breast conservation therapy, 7 (6.6%) required mastectomy. There were 6 recurrences (6.1%) with a median time for recurrence of 47.5 months (range 27–85 months); four recurrences were comedo and two were noncomedo at original diagnosis. Conclusions: The determination of lumpectomy margins in DCIS patients using imprint cytology leads to an overall recurrence rate of 6.1% with reduction in operative time, and re-excision rate. Significant recurrence rates were associated with microinvasion and multifocal tumors (28%) versus simple DCIS at 5 years. Breast conservation therapy and surgical margin determination with imprint cytology for DCIS is a cost-effective and reliable method of treatment for simple DCIS.     

Locally recurrent breast cancer after conservation therapy

BACKGROUND: Today, the majority of small invasive and noninvasive breast cancers are treated with breast conservation therapy (BCT). The incidence of local-regional recurrence (LRR) after BCT for stage 0, I, and II patients ranges between 5% and 22%. METHODS: A literature search for BCT, local recurrence, and regional recurrence was performed. Data from over 50 articles pertaining to the characteristics, risk factors, detection, management, and prognosis of these patients with LRR after BCT were collected and analyzed. RESULTS: Positive margins, high-grade ductal carcinoma in situ (DCIS), young age, and the absence of radiation therapy after BCT increase the risk for LRR. Prognosis at LRR is impacted by invasive versus noninvasive histology, size and stage, method of detection, and involvement of skin and/or axillary lymph nodes. The standard treatment is salvage mastectomy. CONCLUSIONS: The prognosis for LRR after BCT is favorable compared with patients with postmastectomy chest wall recurrence.     

Long-Term Results of Breast Conservation in Chinese Women with Breast Cancer

Abstract:  Between July 1989 and December 2002, 172 women with Stage I/II breast cancer were treated by breast conservation therapy (BCT). All underwent quadrantectomy and axillary node clearance. Minimum follow-up was 5 years and 79 (52%) were followed for >10 years. At 5 years, local relapse-free and overall survival rates were 98.3% and 98.3%. The 10-year rates were 95% and 94%, respectively. The 10-year local recurrence rate was higher in patients with involved margins (33.3% versus 2.7%, p = 0.0272). Furthermore 10-year death rates in margin positive patients were higher (18.2% versus 2.5%, p = 0.0486). Excellent or good cosmetic results were achieved in 54%. BCT is a reasonable option for early stage breast cancer in Chinese women but margin status is the most important determinant of local recurrence. Negative margins are required for optimal local control and minimization of distant metastasis.     

Intraductal carcinoma of the breast: pathologic features associated with local recurrence in patients treated with breast-conserving therapy

Local excision and radiation therapy is a standard treatment option for duct carcinoma in situ (DCIS) of the breast. There is no consensus regarding the significant histologic features associated with recurrence. The authors studied a large group of patients with mammographically detected DCIS treated with breast-conserving therapy to explore DCIS volume relationships, DCIS features, specimen characteristics, and the effect of patient age at diagnosis. Thirteen patients (10%) developed a recurrent carcinoma in the ipsilateral breast, resulting in 5- and 10-year actuarial recurrence rates of 8.9% and 10.3%, respectively. Local recurrences were identified as a true recurrence/marginal miss (TR/MM) in nine patients, and elsewhere in the breast in four patients. The notable features associated with TR/MM recurrences on univariate analysis included patient age less than 45 years old, six or more slides with DCIS, no microscopic calcifications within DCIS ducts, and five or more DCIS ducts or terminal duct lobular units (TDLUs) with cancerization of lobules (COL) within 0.42 cm of the final surgical margin. DCIS tumor size, nuclear grade, amount of central necrosis, and margin status were not associated with outcome. Multivariate analysis found that the absence of microcalcifications within DCIS ducts, patient age, number of slides with DCIS or TDLUs with COL, and the number of DCIS ducts or TDLUs with COL within 0.42 cm of the final margin were related significantly to TR/MM recurrence. Patients with a total of six or more slides with DCIS, or who have 11 or more DCIS ducts or TDLUs with COL near the final margin are at increased risk of having a substantial volume of residual DCIS in the adjacent unexcised breast. These results suggest that the volume of DCIS in the specimen, and the volume of DCIS near the margin are associated with local recurrence. These features can be used to identify those patients with a higher chance of local recurrence.     

The Use of Oncoplastic Reduction Techniques to Reconstruct Partial Mastectomy Defects in Women with Ductal Carcinoma In Situ

Abstract: The application of oncoplastic techniques to breast conservation therapy (BCT) is thought to improve cosmetic results with some documented oncologic advantages in certain patients. Although present data highlight the oncologic safety of this approach, the role of oncoplastic surgery specific to ductal carcinoma in situ (DCIS) has not been elucidated. In this study, all women in the Emory Healthcare system between January 1991 and June 2006 with biopsy‐proven DCIS who underwent lumpectomies combined with simultaneous reduction mammaplasties or mastopexies were identified. Medical records, including office notes, operative and pathology reports were analyzed. Parameters included age, BMI, histologic grade (low, intermediate, high) and type (comedo versus non‐comedo) of DCIS, margin status, locoregional recurrence, specimen weight, postoperative complications, and overall outcomes. Pedicle design and contralateral breast pathology were also analyzed. Twenty‐eight women were included in the study with an average age of 47. Therapeutic mammaplasty was the definitive procedure for 18 (64%) of these patients. Ten patients (36%) required reoperations: nine for positive margins and one for residual microcalcifications (stereo biopsy DCIS). Overall, seven patients (25%) required completion mastectomy with reconstruction (transverse rectus abdominus myocutaneous flap: n = 3, latissimus flap: n = 4), whereas three patients (11%) underwent re‐excisions with confirmation of negative margins. All ten women who required completion mastectomy or re‐excisions exhibited either intermediate or high‐grade, comedo DCIS. Overall, 50% (6/12) of women diagnosed with high‐grade comedo DCIS required completion mastectomy with reconstruction after initial therapeutic mammaplasty. The final positive‐margin rate for women diagnosed with intermediate‐grade, comedo necrosis was 43% (3/7). The women in this failed group that required reoperations were overall younger (mean: 45.6; median: 43) than those in which oncoplastic surgery was the definitive procedure (mean: 57.8; median: 57). There were no significant differences between the failed and successful groups in terms of biopsy weight (failed: 253 g, successful: 237 g), type of excision (e.g., wire‐localized), location of tumor, reduction type (e.g., superior medial), or postoperative complications. There was one case of locoregional recurrence of DCIS 7 months after the initial operation. All 28 patients had no evidence of disease at an average follow‐up of 2.7 years. This study suggests that although oncoplastic reduction techniques are a reasonable approach for women with DCIS, stricter patient selection and improved confirmation of negative margins will minimize the need for either re‐excisions or completion mastectomy and reconstruction.     

Accuracy of intraoperative gross examination of surgical margin status in women undergoing partial mastectomy for breast malignancy

Margin status is an important prognostic factor for local recurrence after partial mastectomy for breast malignancy. Options for intraoperative evaluation of margin status include gross examination of the specimen, frozen section, and "touch preparation" cytology. This study evaluates the accuracy of gross examination without other intraoperative pathological analysis as a method of determining margin status. Records of 254 consecutive patients undergoing partial mastectomy for 255 breast malignancies (199 invasive, 56 DCIS) over 6 years were analyzed retrospectively. All women underwent en bloc excision of the primary lesion with gross examination of margin status by the surgeon and pathologist. All suspicious areas were reexcised, and the specimen was inked, serially sectioned at 2-3 mm intervals and examined with hematoxylin and eosin (H&E) stains. Specimens with tumor <2 mm from a margin were considered margin-positive and those with all tumor > or =2 mm from the margin were designated margin-negative. One hundred fourteen (45%) of the 255 segmental resections were considered to have grossly tumor-free margins, and intraoperative reexcision was not performed. Ninety-six (84%) of these specimens had histologically negative margins. Gross examination prompted intraoperative reexcision in 141 (55%) cases. Ninety-five (67%) of these 141 resections had tumor-free margins on histopathology. Overall, the final margin was involved in 64 of the 255 partial mastectomies. Seventeen (27%) women with initially margin-positive resections underwent mastectomy, while 46 (72%) underwent reexcision, which was margin-negative in 41 (89%). After a median follow-up of 42 months, there have been eight (3.5%) local recurrences. The initial margin-positive rate was similar in ductal carcinoma in situ (DCIS) (30%) and invasive carcinoma (24%). Margin status was correlated with nodal status; there was no correlation with age, tumor size, grade hormone receptor status, or type of diagnostic biopsy. Gross examination of the resection specimen does not reflect margin status in at least 25 per cent of women undergoing partial mastectomy for breast malignancy. Other techniques for evaluation of margin status should be considered to reduce the need for reexcision of involved margins. We are currently designing a prospective clinical trial to examine the efficacy of new techniques for intraoperative evaluation of margin status.     

Long-term outcomes after breast conservation therapy for early stage breast cancer in a community setting

We, as a large community practice, retrospectively reviewed our experience in treating early stage breast cancer to determine rates of breast-conserving therapy (BCT), disease outcomes after such treatment, and risk factors for local recurrence. A hospital tumor registry was used to identify breast cancer cases diagnosed between 1987 and 2003. Rates of BCT and radiotherapy were examined using primary treatment data. For subsequent disease outcomes analyses, cases were limited to only those treated between 1987 and 1994 to allow for adequate follow-up. For the subset of 521 T1-2N0 patients treated with BCT, we calculated crude rates of first failure at 8 years, with outcomes classified as local failure (LF), distant or regional node failure (DNF), dead without failure (DWF), or alive without failure (AWF). Polychotomous logistic regression was done to assess the influence of age at diagnosis, tumor grade, total radiation dose to the tumor bed, and use of systemic therapy. From 1987 to 2003, rates of BCT went from 69% to 89% and the rate of radiation after breast-conserving surgery was 90%. For the subset of 521 T1-2N0 patients treated with BCT who had at least 8 years of follow-up, median age was 58 years, 15% had grade 1 tumors, 83% had T1 tumors, 4.6% had positive margins, 83% got a total radiation dose >or=60 Gy to the tumor bed, and 51% had systemic therapy. At 8 years, 7% of patients had LF, 8% DNF, 10% were DWF, and 75% were AWF. Patient age (p = 0.076), tumor grade (p = 0.056), use of systemic therapy (p = 0.077), and radiation dose (p = 0.127) had borderline significant effects on the risk of LF versus AWF. The majority of patients in this community were treated with BCT and most received radiotherapy. Local control was excellent and comparable to that seen in large academic centers.     

Variations Among Individual Surgeons in the Rate of Positive Surgical Margins in Radical Prostatectomy Specimens

PurposeCancer at the resection margin (a positive surgical margin) after radical prostatectomy is associated with an increased risk of recurrence even after adjusting for other known risk factors, including pretreatment serum prostate specific antigen (PSA), clinical stage, grade and pathological stage (level of extracapsular extension, seminal vesicle invasion and pelvic lymph node status). Of these prognostic factors only surgical margin status can be influenced by surgical technique. We examined variations in the rate of positive surgical margins among surgeons after controlling for the severity of disease and volume of cases per surgeon.Materials and MethodsA total of 4,629 men were treated with radical prostatectomy by 1 of 44 surgeons at 2 large urban centers between 1983 and 2002 for clinical stage T1-T3NxM0 prostate cancer. Patients were excluded if they had previously received androgen deprivation therapy or radiation therapy to the pelvis. Positive surgical margins were defined as cancer at the inked resection margin. Other risk factors analyzed were serum PSA, grade (Gleason sum), extracapsular extension level (none, invasion into the capsule, present [not otherwise specified], focal extracapsular extension or established extracapsular extension), seminal vesicle invasion, pelvic lymph node metastases, surgery date, surgeon and volume of cases per surgeon.ResultsFor the 26 surgeons who each treated more than 10 patients in the study the rate of positive surgical margins was 10% to 48%. On multivariable analysis higher serum PSA, extracapsular extension level, higher radical prostatectomy Gleason sum, surgery date, surgical volume and surgeon were associated with surgical margin status after controlling for all other clinical and pathological variables.ConclusionsWhile the clinical and pathological features of cancer are associated with the risk of a positive margin in radical prostatectomy specimens, the technique used by individual surgeons is also a factor. Lower rates of positive surgical margins for high volume surgeons suggest that experience and careful attention to surgical details, adjusted for the characteristics of the cancer being treated, can decrease positive surgical margin rates and improve cancer control with radical prostatectomy.     

Surgical management of ductal carcinoma in situ in Australia in 1995

Background: In the present paper we describe the presentation and management of ductal carcinoma in situ (DCIS) of the breast in women in Australia in 1995. This representative, national data set provides a historical comparator for studies examining DCIS management that follow. Methods: Surgeons identified by population‐based cancer registries as having treated a new diagnosis of DCIS between 1 April and 30 September 1995 completed a questionnaire on the presentation and management of each case. Results: Two hundred and five surgeons supplied treatment details on 418 DCIS tumours in 415 women . Half of all tumours were detected at BreastScreen clinics and a further 25% were detected at other mammography centres. Twenty‐six percent of tumours were palpable at presentation, 33% were multifocal and 55% were high grade (including comedocarcinoma). Breast conserving therapy (BCT) rather than mastectomy was utilized in 260 (62%) of cases. Tumours that were of low grade, small in size and not multifocal were more likely to be treated by BCT. Surgeons seeing six or more DCIS cases in the 6‐month period were more likely to utilize BCT. Of the conservatively treated cases, 22% were referred for a radiation oncology consultation. The most common reasons for treating DCIS with mastectomy were that the tumour was too extensive or multifocal (63%), it extended to margins of the specimen (42%), or patient concerns about recurrence (34%). Conclusions: In 1995 the majority of DCIS was treated with breast conserving surgery alone. Surgeons treating more DCIS cases were more likely to perform conservative surgery than surgeons treating only one DCIS case in the study period.     

Targeted Intraoperative Radiotherapy for the Management of Ductal Carcinoma In Situ of the Breast

Multiple long‐term studies have demonstrated a propensity for breast cancer recurrences to develop near the site of the original breast cancer. Recognition of this local recurrence pattern laid the foundation for the development of accelerated partial breast irradiation (APBI) approaches designed to limit the radiation treatment field to the site of the malignancy. However, there is a paucity of data regarding the efficacy of APBI in general, and intraoperative radiotherapy (IORT), in particular, for the management of ductal carcinoma in situ (DCIS). As a result, use of APBI, remains controversial. A prospective nonrandomized trial was designed to determine if patients with pure DCIS considered eligible for concurrent IORT based on preoperative mammography and contrast‐enhanced magnetic resonance imaging (CE‐MRI) could be successfully treated using IORT with minimal need for additional therapy due to inadequate surgical margins or excessive tumor size. Between November 2007 and June 2014, 35 women underwent bilateral digital mammography and bilateral breast CE‐MRI prior to selection for IORT. Patients were deemed eligible for IORT if their lesion was ≤4 cm in maximal diameter on both digital mammography and CE‐MRI, pure DCIS on minimally invasive breast biopsy or wide local excision, and considered resectable with clear surgical margins using breast‐conserving surgery (BCS). Postoperatively, the DCIS lesion size determined by imaging was compared with lesion size and surgical margin status obtained from the surgical pathology specimen. Thirty‐five patients completed IORT. Median patient age was 57 years (range 42–79 years) and median histologic lesion size was 15.6 mm (2–40 mm). No invasive cancer was identified. In more than half of the patients in our study (57.1%), MRI failed to detect a corresponding lesion. Nonetheless, 30 patients met criteria for negative margins (i.e., margins ≥2 mm) whereas five patients had positive margins (<2 mm). Two of the five patients with positive margins underwent mastectomy due to extensive imaging‐occult DCIS. Three of the five patients with positive margins underwent successful re‐excision at a subsequent operation prior to subsequent whole breast irradiation. A total of 14.3% (5/35) of patients required some form of additional therapy. At 36 months median follow‐up (range of 2–83 months, average 42 months), only two patients experienced local recurrences of cancer (DCIS only), yielding a 5.7% local recurrence rate. No deaths or distant recurrences were observed. Imaging‐occult DCIS is a challenge for IORT, as it is for all forms of breast‐conserving therapy. Nonetheless, 91.4% of patients with DCIS were successfully managed with BCS and IORT alone, with relatively few patients requiring additional therapy.     

Margin width as the sole determinant of local recurrence after breast conservation in patients with ductal carcinoma in situ of the breast

BACKGROUND: A previous study showed a 3% local recurrence risk at 8 years in ductal carcinoma in situ (DCIS) patients treated with excision alone with surgical margins of 10 mm or greater. This study updates those data. METHODS: A total of 272 DCIS patients treated conservatively with 10 mm or greater margins were reviewed in a prospective database. RESULTS: Among 212 excision-alone patients, there were 9 DCIS and 3 invasive recurrences. The 12-year probability of any local recurrence was 13.9%; of invasive recurrence it was 3.4%. Among 60 excision plus radiation patients, there was 1 local (invasive) recurrence (P = .06). The 12-year probability of local recurrence was 2.5%. CONCLUSIONS: Local recurrence in DCIS patients treated with excision alone with margins of 10 mm or greater compares favorably with local recurrence in DCIS patients with nontransected margins and treated with postoperative radiation. The risk of invasive recurrence among widely excised DCIS patients is extremely low.