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.     

Prediction of pathological margin status using preoperative contrast‐enhanced MRI in patients with early breast cancer who underwent skin‐sparing mastectomy

Skin‐sparing mastectomy (SSM) with immediate reconstruction is standard surgical treatment for early breast cancer with widespread ductal carcinoma in situ (DCIS). The local recurrence rate after SSM is up to 7.0%. We investigated prediction of the pathological margin using contrast‐enhanced MRI, and evaluated the cut‐off point to obtain the safety margin. We performed SSM with immediate reconstruction in 216 early breast cancer patients with widespread DCIS and/or invasive cancer from January 2014 to December 2015. Forty cases were retrospectively reviewed after excluding those with >15 mm between skin and tumor, determined by preoperative contrast‐enhanced MRI, or involving reconstructive surgery for local recurrence, immeasurable lesion by preoperative contrast‐enhanced MRI, or neoadjuvant chemotherapy. We defined a positive pathological margin as <1 mm from the cancer nest. We reviewed the distance between skin and tumor by MRI and pathological examination. To identify the cut‐off for predicting a positive pathological margin, we performed sensitivity analysis using an ROC curve. The margin‐positive rate by pathological examination was 27.5% (n = 11/40), with a moderate correlation of MRI margin and pathological margin (r = 0.44). The best cut‐off point for margin positivity was 5 mm of MRI margin, with sensitivity and specificity of 54% and 86%, respectively (P = 0.009). This is the first prediction of pathological margin by preoperative contrast‐enhanced MRI in early breast cancer patients with SSM. Care is required for SSM if the MRI margin is less than 5 mm due to pathological margin positivity.     

A Phase II Trial of Image-Guided Radiofrequency Ablation of Small Invasive Breast Carcinomas: Use of Saline-Cooled Tip Electrode

Background Local ablative therapy of breast cancer represents the next frontier in the evolution of minimally-invasive breast conservation therapy. We performed this Phase II trial to determine the efficacy and safety of Radiofrequency (RF) ablation of small invasive breast carcinomas. Methods Seventeen patients with biopsy-proven invasive breast cancer, ≤ 1.5 cm in diameter were enrolled in this trial. Under ultrasound guidance, the tumor and a 5 mm margin of surrounding breast tissue were ablated with saline-cooled RF electrode followed by surgical resection. Pathologic and immunohistochemical stains were performed to assess tumor viability. We examined whether loss of ER, PR receptor and pancytokeratin expression following RF ablation would correlate with non-viability. Results Fifteen patients completed the treatment. The mean tumor size was 1.28 cm. The mean ablation time was 21 minutes using a mean power of 35.5 watts. During ablation, the tumors became progressively echogenic that corresponded with the region of severe electrocautery injury at pathological examination. Of the 15 treated patients, NADPH viability staining was available for 14 patients and in 13 (92.8%), there was no evidence of viable malignant cells. ER, PR expression and pancytokeratin immunohistochemistry analysis were unreliable surrogates for determining non-viability. Following RF ablation, 2 patients developed skin puckering. Conclusions RF ablation is a promising minimally invasive treatment of small breast carcinomas, as it can achieve effective cell killing with a low complication rate. Further research is necessary to optimize this image-guided technique and evaluate its future role as the sole local therapy.     

Surgical margins and risk of locoregional recurrence in invasive breast cancer: An analysis of 10-year data from the Breast Cancer Treatment Quality Assurance Project

AimThere is debate as to what constitutes an adequate excision margin to reduce the risk of locoregional recurrence (LRR) after breast cancer surgery. We have investigated the relationship between surgical margin distance and LRR in women with invasive breast cancer (IBC).MethodsTumour free margin distances were extracted from histopathology reports for women with IBC, treated by either breast conserving surgery or mastectomy, enrolled in the Breast Cancer Treatment Group Quality Assurance Project from July 1997 to June 2007. Cox proportional hazards regression analyses were conducted to compare the risk of LRR for involved margins compared with negative margins, measured in increments rounded to the nearest mm.Results88 of 2300 patients (3.8%) experienced an LRR after a mean follow-up of 7.9 years. An involved margin, or a margin of 1 mm was associated with an increased risk of LRR (HR 2.72, 95% CI 1.30–5.69), whilst margin distances of 2 mm or greater were not. Risk of LRR with margin distances <2 mm was particularly high amongst those not receiving radiotherapy (RT).ConclusionBased on our findings, we recommend that a tumour free margin distance of 2 mm be adopted as an adequate margin of excision for IBC, in the setting of patients receiving standard adjuvant RT and adjuvant drug therapies as dictated by the current clinical treatment paradigms.     

Local recurrence after breast‐conserving therapy for phyllodes tumors: A 15‐year retrospective review

There are few data on the long‐term outcomes of patients with phyllodes tumors following breast‐conserving surgery with or without radiation therapy (RT). We reviewed 69 patients diagnosed from 2000 to 2015 with surgical specimens available for central pathology assessment for outcome in relation to histopathologic subtype, margin width, and utilization of RT. Median follow‐up was 63 months (interquartile range, 35‐131 months). Forty‐eight patients had benign, 13 borderline, and eight malignant phyllodes tumors, with local recurrence rates of 4%, 0%, and 38%, respectively (P ≤ .04 comparing malignant lesions to both benign and borderline lesions). None of the eight patients who received RT suffered a local recurrence. Two of the 26 (8%) patients with benign phyllodes tumors who did not receive RT with margins that were positive or <1 mm had local recurrence, compared to none of 18 patients with margins 1 mm or wider who did not receive RT. The one patient with a malignant phyllodes tumor who did not receive RT with margins that were positive or <1 mm did not locally recur, while both patients with margins 10 mm or wider who did not receive RT had local recurrence. One patient with a malignant phyllodes tumor developed distant recurrence following local recurrence. Phyllodes histologic type and margin width were both associated with the risk of local recurrence following breast‐conserving surgery without RT, though the number of events and patients was too small to show these trends were statistically significant.     

Correlating sonography, mammography, and pathology in the assessment of breast cancer size.

BACKGROUND: With the increasing use of neoadjuvant and minimally invasive therapy, the accuracy of preoperative determination of breast tumor size becomes important. Therefore, we undertook this study to compare mammography and ultrasonography (US). METHODS: A total of 180 invasive breast cancer patients were prospectively examined by mammography and US; 146 eligible patients had tumors visualized by both modalities. RESULTS: In 69% of cases, US was better than or equivalent to mammography in determining tumor size. Both underestimated tumor size; mean (median) underestimation was 3.8 +/- 0.7 mm (1.7 mm) by US and 3.5 +/- 0.9 mm (2 mm) by mammogram. Maximal tumor dimension was accurate within 5 mm in 65% of cases by mammography and 75% of cases by US. For mammographically determined size (versus pathologic size) correlation, r, was 0.4 and for US it was 0.63 and improved for only T1 and T2 tumors. CONCLUSIONS: These data suggest that US is more accurate than mammography in assessing breast cancer size.     

Radiofrequency Ablation of Invasive Breast Carcinomas: A Phase II Trial

Background Local ablative therapy of breast cancer represents the next frontier in the minimally invasive breast-conservation treatment. We conducted a phase II trial to evaluate radiofrequency ablation (RFA) of invasive breast carcinomas. Methods Consecutive patients from two Mexican Institutions with invasive breast cancers < 4 cm, with no multicentric tumors and no previous chemotherapy were included in this trial. Under ultrasound guidance, the tumor and a 5 mm margin of surrounding breast tissue were ablated with saline-cooled RFA electrode followed by surgical resection. Routine pathologic analysis and viability evaluation with NADPH-diaphorase stain were performed to assess tumor ablation. Procedure-associated morbidity was recorded. Results Twenty-five patients were included. Mean patient age was 55.3 years (range 42–89 years). Mean tumor size was 2.08 cm (range 0.9–3.8 cm). Fourteen tumors (56%) were <2 cm. The mean ablation time was 11 minutes using a mean power of 35 W. During ablation, the tumors become progressively echogenic that corresponded with the region of severe RFA injury at pathologic examination. Of the 25 patients treated, NADPH stain showed no evidence of viable malignant cells in 19 patients (76%), with significant difference between tumors <2 cm (complete necrosis in 13 of 14 cases, 92.8%) vs. those >2 cm (complete necrosis 6 of 11 cases, 54.5%) (P < .05). No significant morbidity was recorded. Conclusions RFA is a promising minimally invasive treatment of small breast carcinomas, as it can achieve effective cell killing with a low complication rate. Further studies are necessary to optimize the technique and evaluate its future role as local therapy for breast cancer.     

Extreme Oncoplasty: Breast Conservation for Patients Who Need Mastectomy

Extreme oncoplasty is a breast conserving operation, using oncoplastic techniques, in a patient who, in most physicians' opinions, requires a mastectomy. These are generally large, greater than 5 cm multifocal or multicentric tumors. Many will have positive lymph nodes. Most will require radiation therapy, even if treated with mastectomy. Sixty‐six consecutive patients with multifocal, multicentric, or locally advanced tumors that spanned more than 50 mm were studied (extreme cases). All patients underwent excision and oncoplastic reconstruction using a standard or split wise pattern reduction and immediate contralateral surgery for symmetry. All received postexcisional standard whole breast radiation therapy with a boost to the tumor bed. The extreme cases were compared with 245 consecutive patients with unifocal or multifocal tumors that spanned 50 mm or less (standard cases). All extreme patients were advised to have a mastectomy; all sought a breast conserving second opinion. Diagnostic evaluation included digital mammography, ultrasound, MRI, and PET‐CT (if invasive). Standard cases did extremely well. No ink on tumor was achieved 96% of the time among 245 patients. The median tumor size was 21 mm (mean 23 mm). Margins equal or greater than 1 mm were achieved in 88.6% of patients. Seventeen (6.9%) standard patients underwent re‐excision to achieve wider margins and only one patient (0.4%) was converted to mastectomy. With 24 months of median follow‐up, three patients (1.2%) experienced local recurrence. For extreme cases, no ink on tumor was achieved 83.3% of the time, which is comparable to published positive margin rates after standard lumpectomy. The median tumor size was 62 mm (mean 77 mm). Margins equal or greater than 1 mm were achieved in 54.5% of patients. Six (9.1%) extreme patients underwent re‐excision to achieve wider margins and four patients (6.1%) were converted to mastectomy. With a follow‐up of 24 months, one patient (1.5%) experienced a local recurrence. Extreme oncoplasty is a promising new concept. It allows successful breast conservation in selected patients with greater than 5 cm multifocal/multicentric tumors. It may be useful in patients with locally advanced tumors following neo‐adjuvant chemotherapy. From a quality of life point of view, it is a better option than the combination of mastectomy, reconstruction, and radiation therapy. Long‐term data on recurrence and survival are not available, using this approach. Based on historical data, it is expected the local recurrence will be somewhat higher but that there will be little or no impact on survival.     

A Pathologic Assessment of Adequate Margin Status in Breast-Conserving Therapy

Background The definition of a clear margin in breast-conserving therapy is uncertain. The purpose of this study was to correlate the tumor-margin distance of the excision specimen with the presence of residual tumor at reoperation. We also analyzed predictors of compromised margins and of residual disease. Methods All patients who underwent breast-conserving therapy for invasive disease from 1999 to 2003 were reviewed. Pathologic characteristics and the precise tumor distance from the radial margin were recorded. A radial margin was compromised if invasive or (ductal) in situ carcinoma was <5 mm from the margin. Results Of the 612 patients who underwent breast conservation, 211 (34%) had compromised margins, and 39 had undetermined margins. Of the 161 patients who had a reoperation for compromised margins, 87 (54%) had residual disease. Residual disease after reoperation was present in 58% (56 of 96), 56% (9 of 16), and 45% (22 of 49) of those with tumor-margin distances <1 mm, ≥1 and <2 mm, and ≥2 and <5 mm, respectively. There was a progressive decline in residual disease for each millimeter until a rate of 22% for tumor-margin distances of ≥4 mm and <5 mm was reached. Pathologic size (P = .004), an extensive intraductal component (P = .002), referral from a symptomatic rather than a population-based screening program (P = .02), and the absence of a preoperative diagnosis by core biopsy (P < .0001) were predictive of compromised margins. Only young age (<45 years) was predictive of finding residual disease on reoperation (P = .02). Conclusions A total of 45% of patients who had tumor 2 to 5 mm from the radial margin had residual disease on reoperation. Our results support a policy of requiring a 5-mm margin in patients undergoing breast-conserving therapy for invasive disease.     

Oncological Advantages of Oncoplastic Breast‐Conserving Surgery in Treatment of Early Breast Cancer

The standard approach to breast‐conserving surgery is wide local excision of the tumor and radiotherapy. However, a significant number of patients require further surgery to obtain oncologically clear margins, and may obtain a poor cosmetic result following adjuvant radiotherapy. Oncoplastic techniques may result in improved cosmesis, but few studies have investigated the oncological advantage of this approach. The aim of this retrospective study was to compare tumor clearance and the need for further margin excision following standard wide local excision (group A, 121 patients), and oncoplastic breast‐conserving surgery (group B, 37 patients). These techniques included therapeutic mammoplasty, sub‐axillary fat pad rotation mammoplasty, thoraco‐epigastric flap, and central flap. Compared to standard surgery (group A), oncoplastic techniques (group B) can be employed for significantly larger tumors (17.6 mm versus 23.9 mm, p = 0.002). Oncoplastic breast‐conserving surgery results in higher mean specimen weights (58.1 g versus 231.1 g, p < 0.0001), higher specimen volumes (112.3 cm³ versus 484.5 cm³, p < 0.0001), and wider clear margins (6.1 mm versus 14.3 mm, p < 0.0001), resulting in lower rates of further surgery (28.9% versus 5.4%, p = 0.002). There was no statistical increase in complication rates following oncoplastic surgery. Oncoplastic breast‐conserving surgery is more successful than standard wide local excision in treating larger tumors and obtaining wider radial margins, thus reducing the need for further margin excision, which delays adjuvant therapy. There was no increase in postoperative complication rate using an oncoplastic approach.     

Surgical margins in breast-conservation operations for invasive carcinoma: does neoadjuvant chemotherapy have an impact?

BACKGROUND: Regression of breast tumors in response to neoadjuvant chemotherapy is variable. The goal of breast-conservation operation after neoadjuvant chemotherapy is generally to resect any residual tumor with negative margins. There are limited data about the success of achieving negative resection margins in these patients. The purpose of this study was to compare surgical margin involvement of breast-conservation resection specimens from patients treated initially with operation with those from patients receiving neoadjuvant chemotherapy. METHODS: Between January 2003 and June 2006, 478 breast-conservation operations were performed for invasive breast cancer at our institution. Seventy-six patients received neoadjuvant chemotherapy. Data collected included age, tumor size, nodal status, hormonal receptors and Her-2-neu status, lymphovascular invasion, histologic grade and type, use of guidewire, preoperative chemotherapy regimens, and microscopic evaluation of surgical margins. Univariate analyses and a regression model were used to identify factors associated with margin involvement. RESULTS: No statistical difference was observed for margin involvement between patients treated with neoadjuvant chemotherapy and those treated initially with operation (21% versus 18%; p = 0.52). Variables associated with positive margins in a logistic regression model were carcinoma type (43% of all lobular carcinomas had positive margins versus 16% in ductal carcinomas; p = 0.002) and hormonal receptor status (margin involvement was present in 20% of tumors that exhibited hormonal receptors versus 10% in negative receptors tumors; p = 0.014). CONCLUSIONS: Breast conservation after neoadjuvant systemic therapy yields no higher incidence of positive margins than primary surgical treatment. Special consideration should be accorded to lobular carcinoma, because our findings, consistent with previous studies, demonstrate an association with margin involvement.     

Comparative Study of Surgical Margins in Oncoplastic Surgery and Quadrantectomy in Breast Cancer

Background Oncoplastic surgery for breast cancer is a novel concept that combines a plastic surgical procedure with breast-conserving treatment to improve the final cosmetic results. The aim of this study was to evaluate the oncological safety of oncoplastic procedures by studying the status of the surgical margins of the excised tumor specimen in comparison with standard quadrantectomies.Methods Thirty consecutive breast cancer patients undergoing oncoplastic surgery (group 1) and 30 patients undergoing standard quadrantectomy (group 2) were prospectively studied with regard to the stage of breast cancer, the surgical procedures performed, the volume of breast tissue excised, and the histopathology of the tumor specimen, with specific details on surgical margins.Results Patients who underwent oncoplastic surgery (group 1) were younger (mean age, 48.73 years) than patients who had a classic quadrantectomy (group 2; mean age, 55.76 years; P = .022). The mean volume of the excised specimen in group 1 was 200.18 cm³, compared with 117.55 cm³ in group 2 (P = .016). Surgical margins were negative in 25 cases out of 30 in group 1 and 17 out of 30 in group 2 (P = .05). The average length of the surgical margin was 8.5 mm in group 1 and 6.5 mm in group 2, but the difference was not statistically significant (P = .074).Conclusions Oncoplastic surgery adds to the oncological safety of breast-conserving treatment because a larger volume of breast tissue can be excised and a wider negative margin can be obtained. It is especially indicated for large tumors, for which standard breast-conserving treatment has a high probability of leaving positive margins.     

Stereotactically guided laser therapy of occult breast tumors: work-in-progress report

HYPOTHESIS: Mammographically detected breast tumors can be completely ablated with laser energy. DESIGN: Nonrandomized control trial. SETTING: A university hospital ambulatory care center. PATIENTS: Thirty-six patients with mammographically detected well-defined breast tumors were selected. INTERVENTIONS: The diagnosis of malignant neoplasms and determination of prognostic factors were established by image-guided needle-core biopsy. Patients were treated on a stereotactic table, using a 16- to 18-gauge laser probe, with an optic fiber transmitting a predetermined amount of laser energy. A multisensor thermal probe was inserted into the breast adjacent to the laser probe to monitor treatment. In the last 10 patients, the tumor blood flow was evaluated before and after laser therapy with contrast-enhanced color Doppler ultrasound. One to 8 weeks after laser therapy, the tumors were surgically removed and serially sectioned. MAIN OUTCOME MEASURE: Complete necrosis in 66% of tumors. RESULTS: Total tumor ablation with negative margins was observed whenever 2500 J/mL of tumor was given or the thermal sensors recorded 60 degrees C. Microscopic examination at 1 week showed disintegration of malignant cells, with peripheral acute inflammatory response and at 4 to 8 weeks extensive fibrosis. Contrast-enhanced color Doppler ultrasound revealed loss of tumor circulation after therapy, and positron emission tomography scan correlated well with histologic findings. There were no systemic adverse effects. Two patients sustained 3 x 4-mm skin burns around the laser needle. CONCLUSION: A stereotactically guided minimally invasive technique may be effective for the treatment of mammographically detected breast cancer.     

Survey of American and Canadian General Surgeons' Perceptions of Margin Status and Practice Patterns for Breast Conserving Surgery

Although breast conservation surgery (BCS) is commonly performed, several aspects of the procedure remain controversial. We undertook a cross‐sectional survey to compare Canadian (CDN) and American (AM) general surgeons' reported BCS practice patterns to better understand the cross‐border differences in early‐stage breast cancer surgery care. A modified Dillman Method survey was mailed to 1,447 AM and 1,443 CDN surgeons. Factors evaluated included preoperative assessment, margin definition, surgical techniques, and re‐excision practices. The response rate was 26% and 51% for AM and CDN surgeons, respectively. There was variation in use of preoperative core biopsies. American surgeons required wider margins for invasive cancer and ductal carcinoma in situ, and more often recommend re‐excision for invasive cancer with 1 and 2 mm margins (p < 0.05). There was also variability in surgical techniques used for intraoperative margin assessment. Wide variation in BCS practice was observed, with some of this variability related to surgeon country.     

Breast conservation surgery achieving>or=2 mm tumor-free margins results in decreased local-regional recurrence rates

Whether cosmetically acceptable tumor-free (>/=2 mm) surgical margins reduce the local-regional recurrence risk for patients treated with fractionated radiation therapy, chemotherapy, and hormonal therapy is unknown. The benefit of a minimum cosmetically acceptable tumor-free margin remains speculative because no contemporary studies have investigated the extent of invasive disease infiltration within the breast beyond the primary tumor. To address these clinical issues, we conducted a retrospective study of 341 women diagnosed with stage I or II invasive breast cancer to determine the rate of local in-breast, elsewhere in-breast, and ipsilateral regional lymph node recurrences of breast cancer after conservation surgery achieving either tumor-free (>or=2 mm) or close (>0 mm to <2 mm) surgical margins followed by whole breast radiation therapy over a 6-year period from January 1996 to December 2002. Women may have received adjuvant chemotherapy or hormonal therapy as clinically indicated. After a median follow-up of 56 months from the completion of breast conservation surgery, 14 of the 341 women (4.1%) developed breast cancer recurrences. Crude ipsilateral recurrence rates were 1.8% (4 of 222) for tumor-free (>or=2 mm) versus 8.4% (10 of 119) for close (>0 mm to <2 mm) surgical margins (p=0.007). The estimated 5-year cumulative local recurrence rate was significantly less for women with tumor-free margins (2.1%) as compared to close surgical margins (8.9%) (p=0.004). Multivariate analyses identified negative estrogen receptor expression (p=0.004), close surgical margins (p=0.012), and the presence of angiolymphatic invasion (p=0.040) as prognostic factors for local-regional recurrences. Microscopically the extent of invasive disease infiltration beyond the primary tumor was on average 1 mm, with all measured invasive disease less than 1 cm. Based on our findings, cosmetically acceptable tumor-free (>or=2 mm) surgical margins significantly reduce local in-breast and regional lymph node recurrences with fractionated radiation therapy, chemotherapy, and hormonal therapy.     

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.     

Conservative surgery and radiation therapy for macroscopically multiple ipsilateral invasive breast cancers

BACKGROUND: The presence of macroscopically multiple ipsilateral invasive breast cancer (MMIIBC) has been considered a contraindication for breast conservation. Early series reported high rates of local recurrence. A treatment regimen was developed to accommodate patient requests for breast conservation in MMIIBC. METHODS: We reviewed medical records of the 15 MMIIBC patients who underwent partial mastectomy followed by radiation between 1989 and 1997. All patients had 2 or more separate macroscopic tumors greater than 2 mm in diameter. After tumor excision, all specimens were evaluated; the protocol required surgical margins of at least 2 mm. RESULTS: As of June 2000 (median follow-up 76 months), 14 patients (93%) were alive without evidence of disease. One patient died of systemic disease without local recurrence. CONCLUSIONS: In selected cases, the combination of breast conservative surgery and radiation therapy with systemic therapy results in acceptable local-regional control. Patients who present with MMIIBC with clear surgical margins should be considered for breast conservation.     

Low re-excision rate for positive margins in patients treated with ultrasound-guided breast-conserving surgery

BackgroundRe-excision is a necessary procedure in obtaining clean margins for breast-conserving surgery (BCS)-treated patients. Re-excision rates vary widely among different breast cancer management procedures. The aim of this study was to evaluate the efficacy of ultrasound (US)-guided BCS to decrease the re-excision rate in patients with US-detectable breast cancer, as well as the relationship between positive margins and ultrasonographic characteristics of tumor.MethodsBetween 2008 and 2009, we identified consecutive patients who underwent initial US-guided BCS for breast in situ or invasive carcinoma, which was preoperatively detected using US examination and on the basis of image-guided biopsy findings. The margins achieved after BCS were separately assessed by performing frozen section analysis of shaved margins. The negative margin and positive margin groups were compared for clinicopathological features and ultrasonographic findings.ResultsOf 381 patients undergoing US-guided BCS, 126 (33.1%) had palpable tumors and 255 (66.9%) had nonpalpable tumors. Positive margins were noted in 35 patients (9.2%). These patients underwent re-excision and were margin-free; no further surgery was required for these patients. There were no significant intergroup differences in clinicopathological features and ultrasonographic findings.ConclusionBreast US is an effective modality for intraoperative tumor localization and can thus help obtain clean margins and reduce the re-excision rate in cases in which breast-conserving therapy has been performed. Furthermore, frozen section analysis of cavity shaved margins is a feasible method for minimizing the need for further surgery.     

A prospective study of tumor and technical factors associated with positive margins in breast-conservation therapy for nonpalpable malignancy

BackgroundThe purpose of this study was to identify factors that predict an increased risk of a positive surgical margin after breast-conserving therapy for nonpalpable carcinoma of the breast.MethodsIn this prospective study, 305 patients with nonpalpable invasive breast cancer or ductal carcinoma in situ were identified and underwent localization lumpectomy. Patient, technical, and tumor factors with a potential to predict margin status were documented.ResultsA 20% positive margin rate was observed. Univariate analysis of patient, tumor, and technical factors revealed that localizations performed under stereotactic guidance (P < .001), presence of in situ disease, high tumor grade, larger tumor size, multifocal disease, and presence of mammographic microcalcifications (P < .02) were predictive of positive margins. With the exception of tumor grade and mammographic microcalcifications, multivariable analysis identified the same factors.ConclusionsThis study identified several factors associated with positive margins that should be considered when planning breast-conserving therapy for nonpalpable tumors.     

The role of reexcision for positive margins in optimizing local disease control after breast-conserving surgery for cancer

One of the most important factors associated with local recurrence after lumpectomy in breast cancer patients is the status of the surgical margin. Standard surgical practice is to obtain clear margins even if this requires a second surgical procedure. It is assumed that reexcision to achieve clear margins when positive margins are present at initial excision is as effective as complete tumor removal at a single procedure; however, the efficacy of reexcision in this context has not been well studied. A retrospective search of the Henrietta Banting Breast Centre database from 1987 to 1997 identified 1430 patients who underwent lumpectomy for invasive breast cancer: 1225 patients (group A) had negative margins at the initial surgery and 152 patients (group B) underwent one or more reexcisions to achieve negative margins. Fifty-three patients had positive margins at final surgery, but no reexcision was done (group C). Logistic regression was used to identify factors that were predictive of a positive margin; predictors of local recurrence in women whose tumors were completely resected were determined using Cox's proportional hazards model. Patients in groups A, B, and C differed with respect to mean age at diagnosis (58 years, 51 versus, and 56 years, respectively, p < 0.0001), mean tumor size (19 mm, 16 mm, and 26 mm, respectively, p < 0.0001), node positivity (30%, 22%, and 41%, respectively, p = 0.004), and the presence of a ductal carcinoma in situ (DCIS) component (60%, 64%, and 79%, respectively, p = 0.007). The mean follow-up period was similar for the three groups (8 years, 8 years, and 9 years, respectively, p = 0.17). Young age was the only variable predictive of positive margins. Among patients undergoing complete tumor excision, there was a suggestion of a higher 10 year local recurrence rate in reexcision group B, but the difference did not reach statistical significance (11.6% versus 16.6%, p = 0.11). Cox's multivariate regression analyses identified older age, smaller tumor size, receiving radiation therapy, and tamoxifen use as significantly decreasing the rate of local recurrence in patients with negative margins at initial surgery or after reexcision. Our data confirm the results of previous studies indicating that young age is an independent predictor of positive margins after lumpectomy for invasive breast cancer. The only independent predictor of local recurrence in our study cohort was large tumor size. There was a trend toward a higher local recurrence rate if more than one procedure was required to secure clear margins, although this effect was not independent of other factors. Reexcision to clear involved margins is an important surgical intervention for both younger and older women.