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Margins for Conservative Surgery in Stage I and II Invasive Breast Cancer

Guideline Watch |
February 10, 2014

Margins for Conservative Surgery in Stage I and II Invasive Breast Cancer

  1. Henry Mark Kuerer, MD, PhD, FACS

These evidence-based guidelines for breast-conserving surgery with whole-breast irradiation are essential for reducing unnecessary repeat lumpectomy or mastectomy.

  1. Henry Mark Kuerer, MD, PhD, FACS

Approving/Endorsing Organizations: Society of Surgical Oncology, American Society for Radiation Oncology, American Society of Breast Surgeons

Target Population: Surgeons, radiation oncologists, medical oncologists, pathologists

Background and Objective

One of the most controversial issues in breast cancer management concerns the margin width required for invasive breast cancer treated with lumpectomy and whole-breast radiotherapy. Additional surgery for close margins may be unnecessary, may adversely affect cosmetic outcomes, and may add unnecessary costs to healthcare. These consensus guidelines are based on a meta-analysis of margin width and tumor recurrence in 28,162 patients who underwent breast-conserving surgery and whole-breast radiotherapy.

Key Recommendations

  • Positive resection margins warrant additional surgery because they are associated with a twofold increase in local recurrence.

  • Negative margins with no ink on tumor provide optimal outcomes, and routine re-excision is not indicated.

  • Systemic therapy reduces local recurrence, but there is no evidence that wider margins are needed without this treatment.

  • There is no evidence that wider margins of resection are needed regardless of biologic subtype, younger age, invasive lobular carcinoma (or classic lobular carcinoma in situ at a margin), or extensive ductal carcinoma in situ with invasive cancer.

Comment

Our previous understanding of what constitutes an acceptable margin of resection does not reflect recent advances in improved imaging, targeted surgery, enhanced radiotherapy delivery, and modern systemic treatments. Consequently, more than 25% of patients in the U.S. still undergo repeat surgery when initial margins are close but negative (JAMA 2012; 307:467). These new evidence-based guidelines provide compelling evidence that the routine practice of additional surgery to obtain wider margins of resection than ink on tumor is not indicated if patients are receiving whole breast radiotherapy. Nevertheless, each patient's clinical circumstances should be evaluated by a multidisciplinary team. Important exceptions to these guidelines include patients with close margins in the presence of residual suspicious microcalcifications, patients with stage III disease or those receiving neoadjuvant chemotherapy, patients with pure ductal carcinoma in situ, and those who receive only partial breast radiotherapy or no radiotherapy, as these scenarios were not systematically examined in the supporting meta-analysis.

  • Disclosures for Henry Mark Kuerer, MD, PhD, FACS at time of publication Consultant / Advisory board Bayer Pharma AG Speaker's bureau AstraZeneca Grant / research support Susan G. Komen Foundation Leadership positions in professional societies Alliance for Clinical Trials in Oncology (Chair, Education Committee)

Citation(s):

Reader Comments (3)

George Baker Other, Cardiology, Retired with Emeritus license

interested because my wife had undergone Surgery, radiation and Chemo for Stage II Intraductal Carcinoma. now a 5 year survivor but with some osteoporosis on Bone scan

john gorman Other, Oncology, retired

Is anyone at Jwatch following the phase 3 study of a treatment that is looking good for the first line of treatment for tumors that can be reached with an injection? Seems like it can be used to treat multiple positive tumors. Company is Cell Science and drug is multipkine. It has so far no side effects to the patient.

Raul Gutierrez C Physician, Surgery, Specialized, CECAC

Es importante el tema para el cirujano oncologo.

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