Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on medication adherence

LIVE: Thursday 27th June 2024, 18:00-19:30 (CEST)
Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.
ADVANCED SEARCH
Log in
Top
Annals of Surgical Oncology
Published in: Annals of Surgical Oncology 6/2024

Open Access 23-03-2024 | Breast Surgery | Breast Oncology

Clinicopathological Predictors of Positive Resection Margins in Breast-Conserving Surgery

Authors: Hemali Chauhan, MBBS, BSc (Hons), MRCS, Natasha Jiwa, MBBS, BSc (Hons), MRCS, PhD, Vikneswaran Raj Nagarajan, MB, BCh, Paul Thiruchelvam, MBBS, BSc (Hons), FRCS, PhD, Katy Hogben, MBBS, BSc (Hons), FRCS, PhD, Ragheed Al-Mufti, MB, BCh, FRCS, MSc, MD, FRCS, Dimitri Hadjiminas, MD, MPhil, FRCS, Sami Shousha, MD, FRCPath, Ramsey Cutress, MB, BCh, FRCS, PhD, Hutan Ashrafian, PhD, MRCS, MBA, Zoltan Takats, PhD, Daniel Richard Leff, MBBS, FRCS, PhD, MS(Hons)

Published in: Annals of Surgical Oncology | Issue 6/2024

Login to get access

Abstract

Background

Ductal carcinoma in situ (DCIS) is associated with risk of positive resection margins following breast-conserving surgery (BCS) and subsequent reoperation. Prior reports grossly underestimate the risk of margin positivity with IBC containing a DCIS component (IBC + DCIS) due to patient-level rather than margin-level analysis.

Objective

The aim of this study was to delineate the relative risk of IBC + DCIS compared with pure IBC (without a DCIS component) on margin positivity through detailed margin-level interrogation.

Methods

A single institution, retrospective, observational cohort study was conducted in which pathology databases were evaluated to identify patients who underwent BCS over 5 years (2014–2019). Margin-level interrogation included granular detail into the extent, pathological subtype and grade of disease at each resection margin. Predictors of a positive margin were computed using multivariate regression analysis.

Results

Clinicopathological details were examined from 5454 margins from 909 women. The relative risk of a positive margin with IBC + DCIS versus pure IBC was 8.76 (95% confidence interval [CI] 6.64–11.56) applying UK Association of Breast Surgery guidelines, and 8.44 (95% CI 6.57–10.84) applying the Society of Surgical Oncology/American Society for Radiation Oncology guidelines. Independent predictors of margin positivity included younger patient age (0.033, 95% CI 0.006–0.060), lower specimen weight (0.045, 95% CI 0.020–0.069), multifocality (0.256, 95% CI 0.137–0.376), lymphovascular invasion (0.138, 95% CI 0.068–0.208) and comedonecrosis (0.113, 95% CI 0.040–0.185).

Conclusions

Compared with pure IBC, the relative risk of a positive margin with IBC + DCIS is approximately ninefold, significantly higher than prior estimates. This margin-level methodology is believed to represent the impact of DCIS more accurately on margin positivity in IBC.
Appendix
Available only for authorised users
Literature
1.
2.
3.
4.
5.
Jeevan R, Cromwell DA, Trivella M, et al. Reoperation rates after breast conserving surgery for breast cancer among women in England: retrospective study of hospital episode statistics. BMJ. 2012;345:e4505.PubMedPubMedCentralCrossRef
6.
Isaacs AJ, Gemignani ML, Pusic A, Sedrakyan A. Association of breast conservation surgery for cancer with 90-day reoperation rates in New York State. JAMA Surg. 2016;151(7):648–55.PubMedCrossRef
7.
Wilke LG, Czechura T, Wang C, et al. Repeat surgery after breast conservation for the treatment of stage 0 to II breast carcinoma: a report from the National Cancer Data Base, 2004–2010. JAMA Surg. 2014;149(12):1296–305.PubMedCrossRef
8.
de Camargo Cancela M, Comber H, Sharp L. Hospital and surgeon caseload are associated with risk of re-operation following breast-conserving surgery. Breast Cancer Res Treat. 2013;140(3):535–44.PubMedCrossRef
9.
van Leeuwen MT, Falster MO, Vajdic CM, et al. Reoperation after breast-conserving surgery for cancer in Australia: statewide cohort study of linked hospital data. BMJ. 2018;8(4):e020858.
10.
Spilsbury K, Semmens JB, Saunders CM, Hall SE, Holman C. Subsequent surgery after initial breast conserving surgery: a population based study. ANZ J Surg. 2005;75(5):260–4.PubMedCrossRef
11.
Landercasper J, Attai D, Atisha D, et al. Toolbox to reduce lumpectomy reoperations and improve cosmetic outcome in breast cancer patients: the American Society of Breast Surgeons Consensus Conference. Ann Surg Oncol. 2015;22(10):3174–83.PubMedPubMedCentralCrossRef
12.
McCahill LE, Single RM, Bowles EJA, et al. Variability in reexcision following breast conservation surgery. JAMA. 2012;307(5):467–75.PubMedCrossRef
13.
Houssami N, Macaskill P, Marinovich ML, Morrow M. The association of surgical margins and local recurrence in women with early-stage invasive breast cancer treated with breast-conserving therapy: a meta-analysis. Ann Surg Oncol. 2014;21(3):717–30.PubMedPubMedCentralCrossRef
14.
Grant Y, Al-Khudairi R, St John E, et al. Patient-level costs in margin re-excision for breast-conserving surgery. Br J Surg. 2019;106(4):384–94.PubMedCrossRef
15.
Engel J, Kerr J, Schlesinger-Raab A, Sauer H, Hölzel D. Quality of life following breast-conserving therapy or mastectomy: results of a 5-year prospective study. Breast J. 2004;10(3):223–31.PubMedCrossRef
16.
Gonzalez EA, Saltzstein EC, Riedner CS, Nelson BK. Seroma formation following breast cancer surgery. Breast J. 2003;9(5):385–8.PubMedCrossRef
17.
Al-Ghazal S, Fallowfield L, Blamey R. Comparison of psychological aspects and patient satisfaction following breast conserving surgery, simple mastectomy and breast reconstruction. Eur J Cancer. 2000;36(15):1938–43.PubMedCrossRef
18.
Jagsi R, Li Y, Morrow M, et al. Patient-reported quality of life and satisfaction with cosmetic outcomes after breast conservation and mastectomy with and without reconstruction: results of a survey of breast cancer survivors. Ann Surg. 2015;261(6):1198.PubMedCrossRef
19.
Tang SSK, Kaptanis S, Haddow JB, et al. Current margin practice and effect on re-excision rates following the publication of the SSO-ASTRO consensus and ABS consensus guidelines: a national prospective study of 2858 women undergoing breast-conserving therapy in the UK and Ireland. Eur J Cancer. 2017;84:315–24.PubMedCrossRef
20.
21.
Langhans L, Jensen MB, Talman MLM, Vejborg I, Kroman N, Tvedskov TF. Reoperation rates in ductal carcinoma in situ vs invasive breast cancer after wire-guided breast-conserving surgery. JAMA Surg. 2017;152(4):378–84.PubMedPubMedCentralCrossRef
22.
Pilewskie M, Morrow M. Margins in breast cancer: how much is enough? Cancer. 2018;124(7):1335–41.PubMedCrossRef
23.
Houvenaeghel G, Lambaudie E, Bannier M, et al. Positive or close margins: reoperation rate and second conservative resection or total mastectomy? Cancer Manag Res. 2019;11:2507.PubMedPubMedCentralCrossRef
24.
Harris EE, Schultz DJ, Jones HA, Solin LJ. Factors associated with residual disease on re-excision in patients with ductal carcinoma in situ of the breast. Cancer J. 2003;9(1):42–8.PubMedCrossRef
25.
Houvenaeghel G, Lambaudie E, Bannier M, Ribeiro S, Barrou J, Heinemann M. Re-operation and mastectomy rates after breast conservative surgery for positive or close margins: a review. Clin Surg. 2018;3:2149.
26.
Miligy IM, Toss MS, Khout H, et al. Surgical management of ductal carcinoma in situ of the breast: a large retrospective study from a single institution. Breast J. 2019;25(6):1143–53.PubMedCrossRef
27.
Thomas J, Hanby A, Pinder SE, et al. Adverse surgical outcomes in screen-detected ductal carcinoma in situ of the breast. Eur J Cancer. 2014;50(11):1880–90.PubMedCrossRef
28.
Thomas J, Evans A, Macartney J. Radiological and pathological side estimations of pure ductal carcinoma in situ of the breast: a review of 2564 cases from the Sloane Project. Br J Cancer. 2010;102:285–93.PubMedPubMedCentralCrossRef
29.
Meijnen P, Oldenburg HS, Peterse JL, Bartelink H, Emiel JT. Clinical outcome after selective treatment of patients diagnosed with ductal carcinoma in situ of the breast. Ann Surg Oncol. 2008;15(1):235–43.PubMedCrossRef
30.
Aziz D, Rawlinson E, Narod SA, et al. The role of reexcision for positive margins in optimizing local disease control after breast-conserving surgery for cancer. Breast J. 2006;12(4):331–7.PubMedCrossRef
31.
Miller AR, Brandao G, Prihoda TJ, Hill C, Cruz AB Jr, Yeh IT. Positive margins following surgical resection of breast carcinoma: analysis of pathologic correlates. J Surg Oncol. 2004;86(3):134–40.PubMedCrossRef
32.
Mai KT, Chaudhuri M, Perkins DG, Mirsky D. Resection margin status in lumpectomy specimens for duct carcinoma of the breast: correlation with core biopsy and mammographic findings. J Surg Oncol. 2001;78(3):189–93.PubMedCrossRef
33.
Kurniawan ED, Wong MH, Windle I, et al. Predictors of surgical margin status in breast-conserving surgery within a breast screening program. Ann Surg Oncol. 2008;15(9):2542–9.PubMedCrossRef
34.
Shin H-C, Han W, Moon H-G, et al. Nomogram for predicting positive resection margins after breast-conserving surgery. Breast Cancer Res Treat. 2012;134(3):1115–23.PubMedCrossRef
35.
van Deurzen CH. Predictors of surgical margin following breast-conserving surgery: a large population-based cohort study. Ann Surg Oncol. 2016;23(5):627–33.PubMedPubMedCentralCrossRef
36.
Vos E, Gaal J, Verhoef C, Brouwer K, Van Deurzen C, Koppert L. Focally positive margins in breast conserving surgery: predictors, residual disease, and local recurrence. Eur J Surg Oncol. 2017;43(10):1846–54.PubMedCrossRef
37.
Smitt MC, Horst K. Association of clinical and pathologic variables with lumpectomy surgical margin status after preoperative diagnosis or excisional biopsy of invasive breast cancer. Ann Surg Oncol. 2007;14(3):1040–4.PubMedCrossRef
38.
Chagpar AB, Martin RC II, Hagendoorn LJ, Chao C, McMasters KM. Lumpectomy margins are affected by tumor size and histologic subtype but not by biopsy technique. Am J Surg. 2004;188(4):399–402.PubMedCrossRef
39.
Dzierzanowski M, Melville KA, Barnes PJ, MacIntosh RF, Caines JS, Porter GA. Ductal carcinoma in situ in core biopsies containing invasive breast cancer: correlation with extensive intraductal component and lumpectomy margins. J Surg Oncol. 2005;90(2):71–6.PubMedCrossRef
40.
Dillon MF, Hill AD, Quinn CM, McDermott EW, O’Higgins N. A pathologic assessment of adequate margin status in breast-conserving therapy. Ann Surg Oncol. 2006;13(3):333–9.PubMedCrossRef
41.
Volders J, Haloua M, Krekel N, Negenborn V, Barbé E, Sietses C, et al. Neoadjuvant chemotherapy in breast-conserving surgery: consequences on margin status and excision volumes: a nationwide pathology study. Eur J Surg Oncol. 2016;42(7):986–93.PubMedCrossRef
42.
43.
Tang S, Kaptanis S. Variables associated with margin re-excision in breast conserving therapy (BCT)–results from the national margins audit. Eur J Surg Oncol. 2017;43(5):S4.
44.
Morrow M, Van Zee KJ, Solin LJ, et al. Society of Surgical Oncology-American Society for Radiation Oncology-American Society of Clinical Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in ductal carcinoma in situ. Ann Surg Oncol. 2016;23(12):3801–10.PubMedPubMedCentralCrossRef
45.
Moran MS, Schnitt SJ, Giuliano AE, et al. SSO-ASTRO consensus guideline on margins for breast-conserving surgery with whole breast irradiation in stage I and II invasive breast cancer. Int J Radiat Oncol Biol Phys. 2014;88(3):553.PubMedPubMedCentralCrossRef
46.
D’Orsi CJ, Sickles EA, Mendelson EB, Morris EA, et al. ACR BI-RADS® Atlas, breast imaging reporting and data system. Reston, VA: American College of Radiology; 2013.
47.
Patzer RE, Kaji AH, Fong Y. TRIPOD reporting guidelines for diagnostic and prognostic studies. JAMA Surg. 2021;156(7):675–6.PubMedCrossRef
48.
Collins GS, Reitsma JB, Altman DG, Moons KG. Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD): the TRIPOD statement. J Br Surg. 2015;102(3):148–58.CrossRef
49.
Jeevan R, Cromwell D, Trivella M, Lawrence G, Kearins O, Pereira J, et al. Reoperation rates after breast conserving surgery for breast cancer among women in England: retrospective study of hospital episode statistics. BMJ. 2012;345:e4505.PubMedPubMedCentralCrossRef
50.
Wazer DE, Schmidt-Ullrich RK, Ruthazer R, et al. The influence of age and extensive intraductal component histology upon breast lumpectomy margin assessment as a predictor of residual tumor. Int J Radiat Oncol Biol Phys. 1999;45(4):885–91.PubMedCrossRef
51.
Singletary SE. Surgical margins in patients with early-stage breast cancer treated with breast conservation therapy. Am J Surg. 2002;184(5):383–93.PubMedCrossRef
52.
Ellbrant J, Gulis K, Plasgård E, Svensjö T, Bendahl P, Rydén L. Validated prediction model for positive resection margins in breast-conserving surgery based exclusively on preoperative data. Br J Surg. 2021;5(5):092.
53.
Olsen MA, Nickel KB, Margenthaler JA, et al. Increased risk of surgical site infection among breast-conserving surgery re-excisions. Ann Surg Oncol. 2015;22(6):2003–9.PubMedCrossRef
54.
Yu J, Elmore LC, Cyr AE, Aft RL, Gillanders WE, Margenthaler JA. Cost analysis of a surgical consensus guideline in breast-conserving surgery. J Am Coll Surg. 2017;225(2):294–301.PubMedPubMedCentralCrossRef
55.
St John ER, Balog J, McKenzie JS, et al. Rapid evaporative ionisation mass spectrometry of electrosurgical vapours for the identification of breast pathology: towards an intelligent knife for breast cancer surgery. Breast Cancer Res. 2017;19(1):59.PubMedPubMedCentralCrossRef
Metadata
Title
Clinicopathological Predictors of Positive Resection Margins in Breast-Conserving Surgery
Authors
Hemali Chauhan, MBBS, BSc (Hons), MRCS
Natasha Jiwa, MBBS, BSc (Hons), MRCS, PhD
Vikneswaran Raj Nagarajan, MB, BCh
Paul Thiruchelvam, MBBS, BSc (Hons), FRCS, PhD
Katy Hogben, MBBS, BSc (Hons), FRCS, PhD
Ragheed Al-Mufti, MB, BCh, FRCS, MSc, MD, FRCS
Dimitri Hadjiminas, MD, MPhil, FRCS
Sami Shousha, MD, FRCPath
Ramsey Cutress, MB, BCh, FRCS, PhD
Hutan Ashrafian, PhD, MRCS, MBA
Zoltan Takats, PhD
Daniel Richard Leff, MBBS, FRCS, PhD, MS(Hons)
Publication date
23-03-2024
Publisher
Springer International Publishing
Published in
Annals of Surgical Oncology / Issue 6/2024
Print ISSN: 1068-9265
Electronic ISSN: 1534-4681
DOI
https://doi.org/10.1245/s10434-024-15153-8

Other articles of this Issue 6/2024

Annals of Surgical Oncology 6/2024 Go to the issue

Global Health Services Research

Endocrine Surgery at the NIH: History and Contributions

Urologic Oncology

Enhanced Artificial Intelligence Strategies in Renal Oncology: Iterative Optimization and Comparative Analysis of GPT 3.5 Versus 4.0

ASO Perspectives

Adjuvant Nivolumab in Esophageal Cancer with Positive Resection Margins: A Premature Leap?

ASO Visual Abstract

ASO Visual Abstract: Contemporary Analysis of Re-Excision and Conversion to Mastectomy Rates and Associated Health Care Costs for Women Undergoing Breast-Conserving Surgery

Global Health Services Research

From Stroma to Scalpel: Celebrating a Mentor in Science and Surgery

Peritoneal Surface Malignancy

Initial Experience Using Laparoscopic HIPEC for Gastric Cancer with Peritoneal Metastasis: Safety and Outcomes