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).     

Treatment Selection for Patients with Ductal Carcinoma In Situ (DCIS) of the Breast Using the University of Southern California/Van Nuys (USC/VNPI) Prognostic Index

The University of Southern California/Van Nuys Prognostic Index (USC/VNPI) is an algorithm that quantifies five measurable prognostic factors known to be important in predicting local recurrence in conservatively treated patients with ductal carcinoma in situ (DCIS) (tumor size, margin width, nuclear grade, age, and comedonecrosis). With five times as many patients since originally developed, sufficient numbers now exist for analysis by individual scores rather than groups of scores. To achieve a local recurrence rate of less than 20% at 12 years, these data support excision alone for all patients scoring 4, 5, or 6 and patients who score 7 but have margin widths ≥3 mm. Excision plus RT achieves the less than 20% local recurrence threshold at 12 years for patients who score 7 and have margins <3 mm, patients who score 8 and have margins ≥3 mm, and for patients who score 9 and have margins ≥5 mm. Mastectomy is required for patients who score 8 and have margins <3 mm, who score 9 and have margins <5 mm and for all patients who score 10, 11, or 12 to keep the local recurrence rate less than 20% at 12 years. DCIS is a highly favorable disease. There is no difference in mortality rate regardless of which treatment is chosen. The USC/VNPI is a numeric tool that can be used to aid the treatment decision‐making process.     

Value of the Van Nuys Prognostic Index in prediction of recurrence of ductal carcinoma in situ after breast-conserving surgery

BACKGROUND: The Van Nuys Prognostic Index (VNPI), an algorithm based on tumour size, tumour grade, presence of necrosis and excision margin width, is claimed to predict local recurrence after breast-conserving surgery for ductal carcinoma in situ (DCIS). The aim of this study was to examine the validity of the VNPI in a UK population. METHODS: Clinicopathological data, including VNPI subgroups, for 237 patients who had breast-conserving operations for DCIS were examined. Multivariate data analysis was performed using a Cox regression model to examine the independence and relative importance of different variables in predicting recurrence, and to compare the data with those used in derivation of the VNPI. RESULTS: The median follow-up was 47 months. There were 37 ipsilateral local recurrences. Excision margin width (P < 0.001) and tumour grade (by Van Nuys grading (P = 0.014) or simple nuclear grading (P = 0.004)) were the only independent risk factors for local recurrence. Excision margin width had three times more power than grade in predicting local recurrence. Subgrouping data by VNPI score predicted recurrence-free survival (P < 0.001), but stratified 78 per cent of patients into a group with a moderate risk of local recurrence. CONCLUSION: Excision margin width is the most important predictor of local recurrence after breast-conserving surgery for DCIS. The VNPI lacked discriminatory power for guiding further patient management.     

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.     

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.     

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.     

The University of Southern California/Van Nuys prognostic index for ductal carcinoma in situ of the breast

BACKGROUND: The original Van Nuys prognostic index (VNPI) was introduced in 1996 as an aid to the complex treatment decision-making process for patients with ductal carcinoma in situ (DCIS) of the breast. This update adds patient age to the previous predictors of local recurrence in breast preservation patients. METHODS: A prospective database consisting of 706 conservatively patients with DCIS was examined using multivariate analysis. Four independent predictors of local recurrence (tumor size, margin width, pathologic classification, and age) were used to derive a new formula for the University of Southern California (USC)/VNPI. RESULTS: In all, 706 patients with pure DCIS were treated with breast preservation. There was no statistical difference in the 12-year local recurrence-free survival in patients with USC/VNPI scores of 4, 5, or 6, regardless of whether or not radiation therapy was used (P = not significant). Patients with USC/VNPI scores of 7, 8, or 9 received a statistically significant average 12% to 15% local recurrence-free survival benefit when treated with radiation therapy (P = 0.03). Patients with scores of 10, 11, or 12, although showing the greatest absolute benefit from radiation therapy, experienced local recurrence rates of almost 50% at 5 years. CONCLUSIONS: Ductal carcinoma in situ patients with USC/VNPI scores of 4, 5 or 6 can be considered for treatment with excision only. Patients with intermediate scores (7, 8, or 9) should be considered for treatment with radiation therapy or be reexcised if margin width is less than 10 mm and cosmetically feasible. Patients with USC/VNPI scores of 10, 11, or 12 exhibit extremely high local recurrence rates, regardless of irradiation, and should be considered for mastectomy, generally with immediate reconstruction or reexcision if technically possible.     

Ductal Carcinoma In Situ of the Breast: The Van Nuys Experience by Treatment

Abstract: Ductal carcinoma in situ (DCIS) represents a broad biologic spectrum of disease with a wide range of treatment approaches. A lack of clear and universally accepted treatment criteria has resulted in a diverse range of confusing clinical recommendations, distressing to both patients and clinicians. Data is presented on 543 patients treated at The Breast Center in Van Nuys, California: 228 by mastectomy, 185 by excision plus radiation therapy, and 130 by excision alone. The local recurrence-free survival at 5 years was 98% for mastectomy patients, 87% for those who received excision plus radiation therapy, and 79% for those treated with excision alone. The difference between each of the recurrence-free survival curves was statistically significant. Margin width was an important predictor of which breast preservation patients were most likely to benefit from postexcisional radiation therapy. There was no benefit from the addition of radiation therapy for patients with margin widths of 10 mm in every direction. The benefit was intermediate for patients with margin widths of 1–9 mm. Patients with margin widths less than 1 mm received the most benefit from postoperative radiation therapy. Radiation therapy is not without side effects and it should not be routinely added to every breast preservation patient's therapeutic plan. Careful consideration must be given to its risks versus its potential benefits. Numerous prognostic factors, such as nuclear grade, the presence of comedo-type necrosis, tumor size, and margin width can all be used to aid in the treatment decision-making process.     

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.     

Factors influencing local control in patients undergoing breast conservation surgery for ductal carcinoma in situ

BackgroundThe aim of our study was to assess various predictors for local recurrence (LR) in patients undergoing breast conservation surgery (BCS) for ductal carcinoma in situ (DCIS).Materials and methodsAn audit was performed of 582 consecutive patients with DCIS between Jan 1975 to June 2008. In patients undergoing BCS, local guidelines reported a margin of ≥10 mm during the above period. Guideline with regard to margin of excision changes soon after this period.We retrospectively analysed clinical and pathological risk factors for local recurrence in patients undergoing BCS. Statistical analysis was carried out using SPSS version 19, and a cox regression model for multivariate analysis of local recurrence was used.ResultsOverall 239 women had BCS for DCIS during the above period. The actuarial 5-year recurrence rate was 9.6%. The overall LR rate was 17% (40/239. LR was more common in patients ≤50 years: (10/31 patients, 32%) compared to patients > 50 years (30/208, 14%, P = 0.02). Forty three per cent of patients (6/14) with <5 mm margin developed LR which was significantly higher compared to patients with 5–9 mm margin (12%, 3/25) and with ≥10 mm margin (14%, 27/188, P = 0.01). On multivariate analysis age ≤50 years, <5 mm pathological margin were independent prognostic factors for local recurrence.ConclusionOur study shows that younger age (≤50 years) and a margin < 5 mm are poor prognostic factors for LR in patients undergoing breast conservation surgery for DCIS.     

Prognostic implications of positive margins in radical prostatectomy specimens

To evaluate the histopathologic implication of positive margins of prostatectomy specimens in the biochemical recurrenceMatherial and methodsThe study group consisted of 290 patients with clinically localized prostate cancer who were treated by radical retropubic prostatectomy. Patients with neoadjuvant hormonal therapy and positive lymph nodes were excluded. The mean age at the time of surgery was 63 years (range 47-73); 166 (57.2%) patients were T1c and 124 (42.8%) T2; the average time of folow-up was of 4 years (range 1-12). Positive surgical margins were defined as the presence of cancer cells at the surface inked of prostatectomy specimens. They were classified as: Margin for capsular incision (without extraprostatic extension evidence)/ margin for extraprostatic extension, margin with smooth rounded surface/margin with irregular surface, margin ≤4 mm/margin >4 mm, unifocal margin/multifocal margin. We define biochemical recurrence if the PSA exceeds 0.20 ng/ml in two consecutive determinationsResultsThe overall rate of positive margins was 65/290 (22.4%). The 5-year survival free of biochemical recurrence was as follows: Negative margins 71% vs positive margins 44% (p<0.001); positive margins for capsular incision 84% vs positive margins for extraprostatic extension 33% (p<0.01); positive margins with smooth rounded surface 58% vs positive margins with irregular surface 26% (p<0.01); positive margins ≤4 mm 57% vs positive margins >4 mm 32% (p<0.05); unifocal margins 53% vs multifocal margins 0% (p<0.01). The multivariate analysis revealed that preoperative PSA, Gleason score and pathological classification were the best predictors of biochemical recurrenceConclusionsTwo groups are established of positive margin. The first group with high probability of biochemical recurrence: margin for extraprostatic. The second group with less probability of biochemical recurrence: margin for capsular incision, margin with smooth rounded surface, margin ≤4 mm and unifocal margin     

Duct carcinoma in situ: A personal perspective

In the recent past, DCIS was a rare diagnosis established by biopsy of palpable breast masses or nipple changes. Mammography increased the frequency of a DCIS diagnosis by 20 × resulting in a tsunami of small circa 10 mm lesions detected only by mammography. The impact of pathologic technique in examining and characterizing such lesions is reviewed, and the development of algorithms incorporating prognostic factors and histology based on serial sequential processing techniques are described and contrasted with those which relied on tissue sampling. The development of the initial clinical trails of irradiation all demonstrated the significant benefit of irradiation but none could identify subsets with a more favorable outcome. The latter was precluded by their common practice of tissue sampling: Size could not be calculated and margin width and microinvasion could not be reliable demonstrated. Multigene signature assays are increasingly being utilized, most prominently Oncotype DCIS. However, these assays must be interpreted in conjunction with the limitations set forth in the validating studies—in the case of Oncotype DCIS—the size, margin width, and grade which defined the baseline study (E5194). Tamoxifen and other anti‐hormonal agents (aromatase inhibitor therapy) have been shown to have a limited impact on ipsilateral recurrence which makes their use given their morbidities problematic. Such interventions do impact the frequency of contralateral occult in situ and invasive lesions. In the one study which permitted a comparison of local recurrence in irradiated vs nonirradiated breast, there was no added benefit of Tamoxifen in irradiated breasts. Some are attempting to identify a low‐risk subset of DCIS which can be treated without surgical re‐excision for margins or adjuvant irradiation. These studies are in progress but surrogates identified within the Van Nuys prospective series defined by grade and inadequate margins (≤ 1 mm) would suggest a significant recurrence and progression rate. DCIS remains a work in progress both in terms of classification and treatment. However, limited our progress in these areas we have certainly advanced from the oft‐proclaimed mantra: “Radiation and Tamoxifen are standard of care.”     

Local recurrence of ductal carcinoma in situ after skin-sparing mastectomy

BACKGROUND: The incidence of local recurrence (LR) after conventional total mastectomy for ductal carcinoma in situ (DCIS) ranges from 1% to 3%. Skin-sparing mastectomy (SSM) preserves the native skin envelope to facilitate immediate breast reconstruction. Because DCIS is generally not clinically apparent, there is a potential for inadequate excision when SSM is performed. Risk factors for local recurrence after SSM for DCIS are examined. STUDY DESIGN: A retrospective review of 223 consecutive patients with DCIS treated by SSM and immediate reconstruction was performed. Age younger than 50 years, tumor size > 40 mm, high tumor grade, tumor necrosis, surgical margins < 1 mm, type of biopsy (excisional versus core), and SSM type were examined as risk factors for recurrence. RESULTS: Mean followup was 82.3 months (range 4.9 to 123.2 months). Recurrences developed in 11 patients (5.1%), including: local (n = 7; 3.3%), regional (n = 2; 0.9%), and distant (n = 2; 0.9%). All seven local recurrences were detected by physical examination. No patients received adjuvant radiation therapy. Two of 19 patients with surgical margins < 1 mm developed LR (10.5%). Univariate analysis showed high tumor grade (p = .019) to influence LR. CONCLUSIONS: The incidence of local recurrence of DCIS after SSM is similar to conventional total mastectomy. Reexcision of close margins should be performed if possible and adjuvant radiation therapy should be considered.     

Circumferential margin involvement is still an important predictor of local recurrence in rectal carcinoma: not one millimeter but two millimeters is the limit

Despite improved surgical treatment strategies for rectal cancer, 5-15% of all patients will develop local recurrences. After conservative surgery, circumferential resection margin (CRM) involvement is a strong predictor of local recurrence. The consequences of a positive CRM after total mesorectal excision (TME) have not been evaluated in a large patient population. In a nationwide randomized multicenter trial comparing preoperative radiotherapy and TME versus TME alone for rectal cancer, CRM involvement was determined according to trial protocol. In this study we analyze the criteria by which the CRM needs to be assessed to predict local recurrence for nonirradiated patients (n = 656, median follow-up 35 months). CRM involvement is a strong predictor for local recurrence after TME. A margin of < or = 2 mm is associated with a local recurrence risk of 16% compared with 5.8% in patients with more mesorectal tissue surrounding the tumor (p <0.0001). In addition, patients with margins < or = 1 mm have an increased risk for distant metastases (37.6% vs 12.7%, p <0.0001) as well as shorter survival. The prognostic value of CRM involvement is independent of TNM classification. Accurate determination of CRM in rectal cancer is important for determination of local recurrence risk, which might subsequently be prevented by additional therapy. In contrast to earlier studies, we show that an increased risk is present when margins are < or = 2 mm.     

Association of Positive Transection Margins with Gastric Cancer Survival and Local Recurrence

Purpose

To examine the association between positive resection margins and survival and local recurrence in patients with gastric cancer undergoing resection with curative intent.

Methods

Patients who underwent curative intent resection for gastric carcinoma from 1985 to 2010 were identified from a prospectively maintained database. Positive margins were defined as disease present at the line of luminal transection. Clinicopathological features and outcome of patients undergoing gastrectomy with negative and positive margins were compared.

Results

Among 2384 patients undergoing curative intent resection, 108 (4.5 %) had positive margins. Positive margins were associated with higher American Joint Committee on Cancer (AJCC) stage, T stage, N stage, median number of positive nodes, diffuse Lauren type, and poorly differentiated tumors. Treatment of positive margins consisted of: observation (39 %), chemoradiotherapy (26 %), chemotherapy (20 %), repeat resection (10 %), radiotherapy (4 %), and unknown (1 %). Multivariate analysis of the entire cohort demonstrated margin status, T stage, N stage, grade, and perineural invasion to be independent predictors of survival. Margin status was an independent predictor of survival in patients with ≤3 positive nodes or T1–2 disease but was not in patients with >3 positive nodes or T3–4 disease. Local recurrence occurred in 16 % of patients with a positive margin. We identified no factors predictive of local recurrence in patients with positive margins.

Conclusions

Positive resection margin is associated with advanced AJCC stage and aggressive tumor biology but remains an independent predictor of worse survival. The significance of a positive margin in gastric cancer is confined to patients with nontransmural disease and/or limited nodal involvement.

     

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.     

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.     

Trends in the surgical treatment of breast cancer

Here, we review the relationship between local recurrence (LR) and disease burden, biology, and targeted therapy. There is still little consensus on what constitutes an adequate margin for breast-conserving surgery, and it is not clear that margins more widely clear than tumor not touching ink decrease LR further. It is important to recognize that clear margins do not indicate the absence of microscopic tumor in the breast and that differences in margin width of a few millimeters do not alter the rates of LR. The molecular subtype of cancer is a powerful predictor of both distant and local relapse risk. Effective systemic therapy, targeted therapy in particular, significantly decreases LR. It is extremely unlikely that there is one margin width that is appropriate for all patients with breast cancer. Further progress in the individualization of local therapy requires a move beyond the fixation on disease burden and the recognition that extent of local therapy should be tailored to tumor biology.     

Size of surgical margin does not influence recurrence rates after curative liver resection for colorectal cancer liver metastases

BACKGROUND: The aim of this study was to examine the relationship between surgical margin status and site of recurrence after potentially curative liver resection for colorectal metastases using an ultrasonic dissection technique. METHODS: Between January 2000 and December 2003, 176 patients underwent liver resection with curative intent for colorectal metastases at a single institution. Demographics, operative data, pathological margin status, site of recurrence and long-term survival data were collected prospectively and analysed. RESULTS: On pathological analysis, resection margins were positive in 43 patients, negative by 1-9 mm in 110, and clear by more than 9 mm in 23 patients. At a median follow-up of 33 months, 133 of 176 patients had developed a recurrence, only five of whom had recurrence at the surgical margin. Recurrence at the surgical margin was not significantly related to the size of the margin. Overall, the median time to recurrence was 12.6 months, which was independent of surgical margin size, although there was a significantly higher proportion of patients with multiple metastases in the group with a positive margin (P = 0.008). Margin status did not correlate significantly with either recurrence-free or overall survival. CONCLUSION: The rate of recurrence at the surgical margin was low and a positive margin was not associated with an increased risk of recurrence either at the surgical margin or elsewhere.     

Impact of resection margin status after nephron-sparing surgery for renal cell carcinoma

OBJECTIVE: To evaluate whether the negative-margin width after nephron-sparing surgery for renal cell carcinoma (RCC) is associated with tumour recurrence. PATIENTS AND METHODS: In all, 121 patients had nephron-sparing surgery for non-metastatic RCC for elective (85 cases) and imperative (36 cases) indications. Intraoperative frozen sections were routinely obtained and revealed negative margins in all patients. The tumour size and the shortest distance of normal parenchyma around the tumour were assessed. RESULTS: After a mean (range) follow-up of 49.3 (12-113) months, six patients had disease progression (three with local recurrence, two of whom also had distant metastases and pure metastatic disease in three). The mean (range) width of the negative margins was 0.56 (0.1-2.3) cm. The width of the resection margin did not correlate with disease progression, while tumour size was a strong predictor of progression (P < 0.02). The mean tumour size was 5.1 cm in patients with progression and 3.1 cm in patients who remained recurrence-free. CONCLUSIONS: Our data suggest that the width of the resection margin, unlike tumour size, does not influence the risk of tumour recurrence.