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.     

Effect of reexcision on the success of breast-conserving surgery

Background: The success of lumpectomy and radiotherapy is dependent on minimizing the residual tumor burden in the breast. Histologic margin status is one measure of the extent of residual tumor. This study was undertaken to determine the success rate of a single conservative lumpectomy in obtaining negative margins and to evaluate the incidence of residual tumor after biopsies with positive or unknown margins. Methods: This is a retrospective study covering a 5-year period (June 1988–June 1993). Results: Three hundred sixteen women had lumpectomies. In 239, lumpectomy was the initial operation after a positive fine-needle aspiration or as a diagnostic procedure. Thirteen cases had positive margins. Reexcision was performed in 90 cases. The indication for reexcision was a positive margin in 42 cases (4 with gross tumor) and unknown margin status in 48. Nineteen of the reexcisions for positive margins and 20 of the reexcisions for unknown margins contained residual tumor. Eighty-six (96%) of the 90 reexcised patients underwent breast preserving surgery. Patient age, menopausal status, histologic tumor type, tumor size, and clinical presentation were not predictive of residual tumor. Conclusions: The need for reexcision does not preclude breast preservation. Because single-stage lumpectomy is successful in achieving negative margins in 95% of patients, diagnostic biopsy without margin evaluation should be abandoned to avoid routine reexcision.Results of this study were presented at the 47th Annual Meeting of The Society of Surgical Oncology, March 17–20, 1994, Houston, Texas, USA.     

Understanding the mechanisms creating false positive lumpectomy margins

OBJECTIVE: All breast surgeons deal with the frustration of initial pathologic close or positive margins that have no residual cancer upon re-excision. To understand the mechanisms that create false positive margins, specimen handling was standardized in a single surgeon's practice and margin issues were tracked. METHODS: Prospectively over a 3.5-year period, needle-localized lumpectomies for the management of early-stage breast cancer were standardized in all aspects of specimen handling, including surgeon inking and specimen compression for specimen radiography for quality assurance. The current study reviews 220 such cases where the original lumpectomy included a small piece of overlying skin from over the target lesion. All specimen radiography was performed with compression at the skin to deep level to bias the "pancaking" effect of pushing tumor to specimen surface to the deep margin. RESULTS: Of the 220 therapeutic lumpectomies performed for clinical stage 0-2 breast cancer in this fashion, 175 (79.5%) had negative margins by a distance of 10 mm or more. Margins less than 10 mm were classified as close and were present in 20 (9.1%) of cases. These were heavily biased toward margins closer than 2 mm. Positive initial margins accounted for 25 (11.4%) of cases. Of the 45 close or positive margin cases, 12 involved the deep margin only, and on re-excision none was found to have residual tumor. When other single margins were involved, re-excision found tumor in 5 of 14 cases (35.7%). When multiple margins were close or positive, 9 of 19 cases (47.3%) were found to have residual tumor at re-excision. CONCLUSIONS: Specimen compression increases the incidence of false margin positivity. The best predictors of true margin positivity are multiple close or positive margins or margin positivity in a direction not associated with specimen ex vivo compression.     

Intraoperative inking is superior to suture marking for specimen orientation in breast cancer

Margin status is an important indicator of residual disease after breast‐conserving surgery (BCS). Intraoperatively, surgeons orient specimens to aid assessment of margins and guide re‐excision of positive margins. We performed a retrospective review of BCS cases from 2013 to 2017 to compare the two specimen orientation methods: suture marking and intraoperative inking. Patients with ductal carcinoma in situ, T1/T2 invasive cancer treated with BCS were included. Rates of positive margins and residual disease at re‐excision were evaluated. 189 patients underwent BCS; 83 had suture marking, 103 had intraoperative inking and 3 had un‐oriented specimens. The incidence of positive margins was 29% (24 patients) in the suture marked group and 20% (21 patients) in the intraoperative inked group (P = .18). Among the 45 patients with positive margins, 60% of tumors were stage T1, 76% were node negative, 36% were palpable with median tumor size of 1.5 cm. Residual disease was identified on re‐excision in 21% of the suture marked specimens and 57% of intraoperative inked specimens (P = .028). The incidence of residual cancer at re‐excision for positive margins was higher for intraoperatively inked versus suture marked specimens. This finding suggests that intraoperative inking is more effective at guiding re‐excision of positive margins.     

The influence of additional surgical margins on the total specimen volume excised and the reoperative rate after breast-conserving surgery

BACKGROUND: It is unclear whether the additional removal of breast tissue during breast-conserving therapy (BCT) for breast cancer beyond the standard lumpectomy reduces the incidence of inadequate microscopic margins found at pathological examination and subsequent reoperation. This study compares the reoperative rates after initial BCT in 3 groups of patients who underwent lumpectomy with complete resection of 4 to 6 additional margins, lumpectomy with selective resection of 1 to 3 additional margins, or standard lumpectomy. METHODS: Retrospective data were reviewed from 171 selected cases of BCT, from May 2000 to February 2006. Forty-five cases involved lumpectomy with complete resection of 4 to 6 additional margins; 77 involved lumpectomy with selective resection of 1 to 3 additional margins, whereas 49 involved standard lumpectomy. All samples underwent pathologic analysis of inked resection margins by permanent section. The 3 groups were compared for patient demographics, tumor size and histologic subtype, tumor stage, margin status, excised specimen volume, and eventual subsequent reoperation. Adequate surgical margin was defined as any negative margin greater than 2 mm. RESULTS: The group with complete resection of 4 to 6 additional margins had a subsequent reoperation rate of 17.7%, whereas the group with selective resection of 1 to 3 additional margins and the standard lumpectomy group had a subsequent reoperation rate of 32.5% and 38.7%, respectively, because of inadequate margins. The mean total excised specimen volume in the 3 groups was 129.19, 46.04, and 37.44 cm3, respectively. CONCLUSIONS: The complete resection of 4 to 6 additional margins during the initial BCT resulted in the lowest subsequent reoperation rate, and the largest total volume specimen excised among the 3 techniques studied.     

Lumpectomy margins are affected by tumor size and histologic subtype but not by biopsy technique

OBJECTIVE: The effect of the type of biopsy (needle vs. excisional) on lumpectomy margin status has not been well established. The objective of this study was to determine whether needle biopsy is associated with a higher positive margin rate at time of lumpectomy. METHODS: We evaluated this hypothesis in the setting of a prospective multi-institutional study. A total of 3975 patients were enrolled in the University of Louisville Breast Cancer Sentinel Lymph Node Study from May 7, 1998 to June 3, 2003. Patients who underwent lumpectomy at the time of their sentinel lymph node biopsy were the focus of this analysis. Patients with clinical stage T1 N0 and T2 N0breast cancer were eligible; 29 patients were found to have T3 tumors on final pathology. Pathologists at each institution defined margin positivity, and tumor at the inked margin of resection was the study guideline. RESULTS: Median patient age was 59 years, and median tumor size was 1.5 cm. A total of 2658 patients underwent lumpectomy with the following results. The cancer of 1515 patients was diagnosed by fine-needle or core-needle biopsy and of 821 patients was diagnosed by excisional biopsy; in 322 patients the method of diagnosis was unknown. The type of previous biopsy did not significantly affect the positive-margin rate at the time of lumpectomy (13.3% vs. 11.0% for needle and excisional biopsy, respectively, P = 0.107). However, patients with larger tumors were more often found to have a positive margin (11.4% vs. 13.9% vs. 27.6% for T1, T2, and T3 tumors, respectively; P = 0.010). No difference was found in margin status after excision of palpable versus nonpalpable tumors (10.6% vs. 10.9%, respectively, P = 0.743). Histologic subtype, however, did affect margin status (15.8% vs. 9.8% positive margins for lobular vs. ductal type, respectively, P = 0.003). CONCLUSIONS: In this multi-institutional study, increasing tumor size and lobular histologic subtype were associated with a greater likelihood of a positive margin. The type of biopsy, needle or excisional, had no effect on the ability to achieve negative margins.     

Predictors of margin status after breast-conserving operations in an underscreened population

Purpose

Negative margins after lumpectomy remain a prominent issue in breast surgery. The current study was performed to evaluate patient-related variables that affect risk for positive margins in an underscreened population.

Methods

A retrospective review was performed of all patients who underwent breast-conserving operations from 2001 to 2010. Sociodemographic, clinical, and treatment variables were evaluated. One millimeter from tumor to inked margin was considered a negative margin. Univariate and multivariate analyses were performed to identify variables which affect margin status after a lumpectomy.

Results

Over the time period evaluated, 69 patients had positive margins (31 %) and 155 (69 %) had negative margins. Overall use of screening mammography was poor (36 %). In unadjusted analysis, patients with positive margins were less likely to have undergone screening mammography (p?=?0.003) and presented with a palpable mass (p?=?0.01). Histopathologic variables which predicted increased risk for positive margins included larger pathologic size, greater number of pathologically involved lymph nodes, higher pathologic stage, presence of lymphovascular invasion (LVI) and extensive intraductal component (EIC), p?<?0.05. In multivariate analysis, clinical stage, poor histologic grade, LVI, and EIC were associated with positive margins (p?<?0.05). By contrast, use of preoperative chemotherapy was associated with attaining negative margins (p?<?0.05).

Conclusions

Factors associated with positive margins after lumpectomy included poor histologic grade, LVI, and EIC. Use of preoperative chemotherapy was the strongest independent predictor of lower risk for positive margins.     

Analysis of residual cancer after diagnostic breast biopsy: An argument for fine-needle aspiration cytology

Background: Diagnostic breast biopsy (DxBx) requires an effective strategy for strategy for successful treatment of breast cancer by lumpectomy or mastectomy. Clearance of margins is required to achieve local control. Methods: We reviewed 844 malignant diagnostic biopsies. The strategy was to perform DxBx on all nonpalpable lesions and fine-needle aspiration (FNA) on all palpable lesions. When FNA was equivocal, DxBx was performed. After positive DxBx, either the biopsy cavity or FNA-positive breast mass was excised, and margins were documented with touch preparation cytology analysis (TPC) and frozen section (FS) as necessary to achieve negative margins. Results: Ourside institutions referred 430 excisional biopsies. Two hundred twenty-five (52.3%) were found to have residual cancer at surgical excision. Our institution performed 414 biopsies: 169 were performed on nonpalpable lesions in which 58% had residual tumor at resection; 245 were diagnosed by FNA of palpable lesions. Residual disease was found in 12 (5%). Conclusions: Of patients who undergo DxBx, >50% have residual breast cancer. It is recommended that (a) FNA be performed on all palpable masses or DxBx of nonpalpable masses; when cancer is diagnosed, proceed to surgical excision. (b) When lumpectomy is the option, margins should be reexcised and intraoperatively evaluated with TPC and FS at the time of axillary dissection.     

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.     

Defining negative margins in DCIS patients treated with breast conservation therapy: The University of Chicago experience

Management of ductal carcinoma in situ (DCIS) has been evolving and the majority of women are now being treated with breast-conserving surgery and radiation therapy (i.e. breast conservation therapy [BCT]). Controversies still exist regarding the histologic features and margin status that are associated with local recurrence. The goal of this study was to review our institution's experience in patients diagnosed with DCIS and treated with BCT to determine pathologic features that can predict local recurrence, with particular emphasis on the final surgical margin status. We analyzed 103 consecutive patients with DCIS who were treated with BCT between 1986 and 2000. The slides were reviewed to determine the final margin status, type of DCIS, size of DCIS, nuclear grade, presence of necrosis and calcification, and volume of excised specimen. Margins were considered positive when DCIS touched or was transected at an inked margin. Negative margins were further categorized as close (less than 1 mm), 1--5 mm, and more than 5 mm. The size of the DCIS was determined based on either the maximal dimension on a slide or from the number of consecutive slides containing DCIS. Morphology and immunohistochemical profiles of the recurrent DCIS cases were compared with original DCIS. All patients were treated uniformly with external beam radiation therapy to the entire breast (median dose 46 Gy) with a boost to the tumor bed (median dose 14 Gy). The median follow-up was 63 months (range 7--191 months). The actuarial 5-year local control rate was 89%. The median time to local recurrence was 55 months. There were 13 local recurrences, of which 9 recurred as pure DCIS and 4 as invasive ductal carcinomas. Univariate analysis showed a significant association with local recurrence for positive margin (p=0.008), high nuclear grade (p=0.02), and young age at diagnosis (p=0.03). If margins were negative, the 5-year local control was 93%, as compared to 69% if margins were positive. A multivariate analysis showed that early age at diagnosis, positive margin status, and high nuclear grade were independently associated with local recurrence. The morphology and immunohistochemical stains of all nine recurrent DCIS were similar to those of the original DCIS. Breast conservation can be achieved with excellent local control by obtaining microscopically negative margins as strictly defined by DCIS not touching the inked surgical margins, and postoperative radiation that includes boost therapy to the tumor bed.     

Effect of time interval on residual disease in breast cancer

The histologic responses of breast tissue to injury are limited. Needle core biopsies of the breast are associated with displacement of tumor cells, and the incidence of tumor displacement decreases as the time interval between needle core biopsy and subsequent excision increases. This suggests that displaced tumor cells are destroyed by reparative processes induced by tissue injury. Residual tumor in a lumpectomy site may also be subjected to the same destructive processes associated with tissue repair. A total of 259 consecutive cases of infiltrating ductal carcinoma with margin-positive lumpectomies and their associated reexcision specimens obtained over a 7-year period were analyzed for the presence, type, and quantity of residual disease. The overall incidence of residual disease was 69%. Residual infiltrating ductal carcinoma was present in 35% of cases, and residual ductal carcinoma in situ was present in 50%. An increased time interval between lumpectomy and reexcision was associated with a decreased incidence of residual infiltrating carcinoma (p <0.0043); this decrease was not found associated with ductal carcinoma in situ. These findings suggest that the host response to injury may destroy residual infiltrating carcinoma cells in some margin-positive cases.     

Clinicopathologic significance of ductal carcinoma in situ in breast core needle biopsies with invasive cancer

To assess whether the presence and amount of intraductal component (IC) in diagnostic needle core biopsies (NCB) is predictive of an extensive IC (EIC), the authors evaluated 50 invasive ductal carcinomas diagnosed with NCB, and then excised via lumpectomy, with regard to the extent of IC in both the NCB and subsequent lumpectomy specimen. These parameters were compared with each other and with the lumpectomy margin status. Extent of IC in the NCB was evaluated by dividing the number of ducts that contained IC by the total number of tissue cores. A ratio of more than 0.5 was considered EIC (EICc). IC extent in the lumpectomy was established by estimating the percentage of the tumor corresponding to IC and was considered extensive (EIC(L)) if more than 25% and if there was presence of IC away from the invasive tumor. The mean size of resected tumors was 1.6 +/- 0.7 cm. In 29 cases (58%) there was no IC in the NCB (NegICc), 11 cases (22%) exhibited nonextensive IC (NEICc), and 10 cases (20%) demonstrated EICc. A total of 7%, 36%, and 70% of the NegICc, NEICc, and EICc cases respectively had EIC(L)(p < 0.0001). The presence of EIC(L) correlated significantly with close or positive margin status for in situ disease (EIC(L) positive, 12 of 13 [92%] vs EIC(L) negative, 11 of 37 [30%]; p = 0.004). None of the NegICc, 27% of NEICc, and 40% of EICc had a positive margin for in situ neoplasm in the lumpectomy specimen (p = 0.004), and 24%, 18%, and 50% had positive margins for invasive neoplasm (p = not significant). The authors conclude that EICc predicts EIC(L) and constitutes a risk factor for positive lumpectomy margin status-particularly for in situ tumor. EICc may thus be of clinical value in identifying a subset of patients that requires a wider local excision.     

Predicting the likelihood of residual disease in women treated for ductal carcinoma in situ

Background: To identify women at risk for residual disease after excision of ductal carcinoma in situ (DCIS), we assessed the relationship between characteristics of the initial biopsy and the presence of residual DCIS at a subsequent operation.Study Design: We identified 134 consecutive “paired” operations from 112 women who had undergone 2 or more operations for DCIS between February 1995 and December 1996. Cancer status of the margins, patient age and leading presentation, tumor subtype and grade, and the presence of multifocal-extensive disease were assessed as potential predictors.Results: Residual DCIS was found in 60 patients (45%): in 2 of 12 patients (17%) with negative margins, in 11 of 36 (31%) with close margins (< 2 mm), in 30 of 52 (58%) with positive margins, and in 17 of 34 patients (50%) with margins of unknown status. Patients with positive or unknown margins were 7.7 and 8.3 times, respectively, more likely to have residual disease than patients with negative margins (95% CI 1.1–59.1; 1.1–66.4). Patients with clinical presentations were 8.0 times more likely to have residual disease than patients who presented with abnormal mammograms (95% CI 2.3–27.6). Multifocal-extensive DCIS was associated with residual disease (adjusted odds ratio [OR] = 7.7, 95% CI 2.9–20.5), as was comedo subtype (OR = 2.7, 95% CI 1.1–6.7).Conclusions: Positive or unknown biopsy margins, a clinical presentation, multifocal-extensive cancer, and the comedo subtype are associated with higher risk of residual DCIS.     

Evaluation of radical prostatectomy capsular margins of resection. The significance of margins designated as negative, closely approaching, and positive

Capsular margins of resection in radical prostatectomy specimens performed for carcinoma of the prostate are difficult to assess because of the scant soft tissue removed with the prostate. There is little objective information as to the validity of what are designated as positive or negative capsular margins of resection. From January 1, 1984 through June 30, 1989 there were 40 radical prostatectomies performed in which the prostate was initially removed leaving the neurovascular bundle within the patient in order to preserve potency. However, based on the surgeons' gross examination of the prostate at the time of radical prostatectomy, the neurovascular bundle was then subsequently removed during the same operation and submitted to pathology as a separate specimen. In these 40 cases the capsular margin in the region of the neurovascular bundle was assessed blindly without knowledge of tumor presence or absence in the subsequently resected neurovascular bundle, and then compared to whether the neurovascular bundle contained tumor. Of the 10 cases called positive based on review of the radical prostatectomy, only six neurovascular bundles (60%) contained tumor. Eight cases had equivocal margins with tumor extending just to the inked margin, and only one (12.5%) had tumor in the neurovascular bundle. All 20 cases with negative assigned margins had complete removal of tumor from this area with none of the neurovascular bundles containing tumor. This study demonstrated that negative capsular margins in radical prostatectomy specimens often contain only a scant amount of soft tissue. Of the 33 cases with true negative margins, the amount of soft tissue between the inked margin and tumor was only greater than 1 mm in two cases and less than or equal to 1 m in 20 cases (less than 0.5 mm in 13 cases with less than 0.25 mm in eight of these cases). Furthermore, 11 cases with tumor extending to the inked margin of resection showed no residual tumor in additional tissue removed from these regions.     

Is the systematic circumferential tumor cavity shaving a representative sample for the remaining mammary gland? About 75 cases

IntroductionThe conservative surgery is more and more indicated for breast cancer. However, we still fear local recurrence which is mostly due to residual tumors?. Several techniques have been used to minimize theses residual tumors; one of them is the systematic circumferential tumor cavity shaving (SCTCS).MethodsWe sampled 75 female patients who had conservative surgery with positive shaved margins in the anatomopathology examination and to whom a complementary treatment with mastectomy have been decided.ResultsThe median age was 48 years old. The median tumor size was 23 mm. In the histological examination of the tumors, 93% were invasive ductal carcinoma associated in 50% of the cases to the presence of ductal carcinoma in situ (DCIS) where all the lumpectomies had clear margin. For the SCTCS, 62,2% were DCIS and in 17,6% of the cases were invasive ductal carcinoma. A complementary treatment with mastectomy was indicated to all the patients. A residual tumor was detected in the remaining mammary gland in 47,7% of the cases out of which 50% were DCIS. Local recurrence happened in three patients (4,6%) after a median of follow up of 36 months. The overall survival and the disease free survival at five years were respectively 83,6% and 75,5%.ConclusionStandardized lumpectomy cavity shaving provides a backup to lumpectomy margins in conservative breast surgery but it can also be used as a sample for the remaining breast, helping to detect the residual tumor, and decreasing the rates of local recurrence after BCT.     

Breast Conservation Therapy in Patients with Early-Stage Breast Cancer Who Have Undergone a Second Re-Excision of the Primary Tumor Bed: A Report of Four Cases

Abstract: For the women with early-stage breast cancer who are candidates for breast conservation therapy, re-excision of the primary tumor bed has commonly been used in patients for several indications. These indications include positive margin or uncertain margin status of the primary excision or residual microcalcifications on postbiopsy mammogram. If the pathology from the re-excision does not confirm negative margin status, mastectomy is generally recommended. This article examines patients who have undergone a second re-excision (i.e., a lumpectomy followed by two re-excisions) who have been treated with breast conservation therapy rather than a mastectomy.
From September 1977 to November 1995, 1,562 patients underwent breast conserving therapy at this institution. Seven hundred forty of these patients underwent a re-excisional biopsy because of positive or uncertain margin status or residual microcalcifications after the first excision. Four patients (0.5%) underwent a second re-excision because of positive or uncertain margin status or residual microcalcifications on mammogram after the first re-excision. The final margin status after the second re-excision of all four patients was negative. The radiation dose was 4,600–5,000 cGy to the whole breast followed by a conedown to bring the total dose to 6,400–6,800 cGy to the primary tumor bed.
Follow-up in the four patients was 13 years, 4 years, 14 months, and 8 months respectively. All four patients are clinically without disease and have not had a locoregional recurrence. Cosmesis was excellent in all four patients. One patient had an adriamycin-induced recall reaction causing a cellulitis, which resolved with antibiotics. There were no other complications.
Highly selected patients may undergo breast-conserving therapy after a second re-excision. Good outcome and cosmesis can be achieved for this small subset of patients with avoidance of a mastectomy.     

Perpendicular Inked Versus Tangential Shaved Margins in Breast-Conserving Surgery: Does the Method Matter?

BACKGROUND: In breast-conserving surgery (BCS), the method of margin assessment and the definition of a negative margin vary widely. The purpose of this study was to compare the incidence of positive margins and rates of reexcision between two methods of margin assessment at a single institution. STUDY DESIGN: In July 2004, our protocol for margin evaluation changed from perpendicular inked margins (Group A, n=263) to tangential shaved margins (Group B, n=261). In Group A, margins were classified as positive, close, and negative. Margins designated as "close" were further defined as: < or = 1 mm, < or = 2 mm, and < or =3 mm. In Group B, shaved margins (by definition 2 to 3 mm) were reported as positive or negative. RESULTS: The rate of reported "positive" margins was significantly higher in Group B: 127 of 261 (49%) versus 42 of 263 (16%), p < 0.001. But when patients with "positive, close, or both" kinds of margins were combined in Group A, there was no significant difference between the two techniques. Although the shaved margin was 2- to 3-mm thick, the rate of reexcision in Group B was significantly higher when compared with that in patients with "positive, close, or both" < or =3 mm margins in Group A (75% versus 52%, p < 0.001). The likelihood of finding residual disease remained the same (27% versus 32%, p=NS). CONCLUSIONS: The tangential shaved-margin technique results in a higher proportion of reported positive margins and limits the ability of the surgeon to discriminate among patients with close margins, resulting in a higher rate of reexcision. The fact that many, but not all, patients with positive or close margins in both groups underwent reexcision emphasizes the role of surgical judgment in this setting. Longer followup is required to determine equivalency in rates of local recurrence between these two methods of margin assessment.     

Surgical margins after needle-localization breast biopsy

: The use of needle-localization breast biopsy (NLBB) for the early diagnosis of breast cancer is common. The therapeutic adequacy of tumor-free margins following NLBB is unknown. We hypothesized that the presence of residual tumor after reexcision (mastectomy, tylectomy, or quadrantectomy) does not depend on the margin status following NLBB. : Retrospective cohort analysis was performed on 890 consecutive NLBBs executed between January 1990 and June 1994. Patients with invasive breast neoplasia were divided into two groups based on the tumor margins after NLBB. Group 1 were the women with positive margins, and group 2 had negative margins. Breast specimens after reexcision were reviewed for evidence of residual invasive carcinoma. : Invasive neoplasia was present in 107 patients (12%). Surgical margins and definitive records of care were avaliable for 96 of them (90%). All 45 patients in group 1 and 38 (75%) of 51 patients in group 2 underwent reexcision of the initial biopsy site (P = 0.36). Residual invasive carcinoma was present in 10 patients (22%) in group 1 and 3 (8%) in group 2 (P = 0.13). : Invasive breast neoplasia diagnosed by NLBB requires reexcision regardless of tumor margins to achieve complete local surgical eradication of tumor.     

Margin assessment before intraoperative radiotherapy during breast conserving surgery—Does the addition of MarginProbe decrease the need for addition of fractionated whole breast radiation?

When performing Breast Conserving Surgery (BCS) with Intraoperative Radiation Therapy (IORT), positive resection margin necessitates not only re‐lumpectomy—but also the addition of fractionated whole breast radiation. This retrospective study of 106 patients undergoing BCS and IORT aims to evaluate intraoperative margin assessment use in our center, and the contribution of the MarginProbe device (MP) to achieving negative surgical margins. Eleven out of 106 lumpectomy specimens had a total of 17 margins positive for tumor cells. Intraoperative gross pathology identified 6 (43%) involved margins, MarginProbe detected 8 (50%), and their combined use allowed for detection of 12 (70.5%) involved margins. In conclusion, the adjunctive use of intraoperative gross pathology and MarginProbe reduced the number of lumpectomies with positive resection margins by more than 50%, decreasing the need for re‐lumpectomy and the addition of whole breast radiation.     

Value of Three-Dimensional Helical CT Image-Guided Planning for Made-to-Order Lumpectomy in Breast Cancer Patients

The authors reviewed Niigata Cancer Center Hospital's experience treating patients with lumpectomy to evaluate the utility of three-dimensional helical computed tomography (3D-CT) image-guided made-to-order lumpectomy and determine a positive margin rate. From April 1993 to September 2000, 251 breasts in 248 patients were treated with lumpectomy with a 1 cm macroscopic free margin. In 213 breasts (85%), 3D-CT image-guided made-to-order lumpectomy was performed. Thirty-eight breasts (15%) underwent a lumpectomy without 3D-CT. The lumpectomy specimen was sectioned at 5 mm intervals. Margin status was classified as negative (no invasive or ductal carcinoma in situ (DCIS) within 2 mm from the cut surface) or positive. Positive margins were classified as focally positive (invasive or DCIS transected at the margin within 5 mm or one slide) or massively positive. With 3D-CT image-guided lumpectomy, 21% (45/213) of lesions had a positive margin and 42% (16/38) of lesions without 3D-CT image-guided lumpectomy had a positive margin (p = 0.0055). For lesions with massively positive margins, the rates were 9% (4/45) for 3D-CT image-guided lumpectomy and 38% (6/16) for lumpectomy without 3D-CT (p = 0.0152). 3D-CT image-guided made-to-order lumpectomy decreased the positive surgical margin rate. Among patients with positive margins, those with 3D-CT image-guided lumpectomy have less residual cancer than those without 3D-CT.