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01-04-2011 | Breast Oncology

Inadequate Margins of Excision When Undergoing Mastectomy for Breast Cancer: Which Patients are at Risk?

Authors: Fariha Sheikh, MD, Alanna Rebecca, MD, Barbara Pockaj, MD, Nabil Wasif, MD, Ann E. McCullough, MD, William Casey, MD, Peter Kreymerman, MD, Richard J. Gray, MD

Published in: Annals of Surgical Oncology | Issue 4/2011

Abstract

Background

We analyzed the margin status and risk factors for inadequate margins among patients who underwent skin-sparing mastectomies (SSM) and traditional total mastectomies (TM).

Materials and Methods

Patients undergoing mastectomies from 2003 to 2009 were included. Margins of excision were considered positive if carcinoma was at an inked margin and were considered close if such disease was within 2 mm of an inked margin.

Results

A total of 426 patients were identified. The mean age was 60 years and 90% were white. Mean tumor size was 2.6 cm and 44% had multiple ipsilateral carcinomas. Of 426 patients, 177 (42%) underwent SSM with reconstruction and 249 (58%) TM. The rate of positive or close margins on the initial specimen was 29% for SSM vs. 12% for TM (P < 0.01), and the rate of reoperation for margins was 7% for SSM vs. 2% for TM (P < 0.01). Logistic regression analysis revealed that independent risk factors for initial close or positive margins included SSM (odds ratio 2.36, 95% confidence interval [95% CI] 1.05–5.30), multiple ipsilateral tumors (OR 2.12, 95% CI 1.05–4.24), and upper-inner quadrant location (OR 2.58, 95% CI 1.07–6.19). Mean follow-up time was 28 months, and the local recurrence rate was 0.9%. Local recurrence rates were not different for those undergoing SSM (1.1%) vs. TM (0.8%, P = NS).

Conclusions

Mastectomy patients undergoing SSM, with multiple ipsilateral tumors, and/or upper-inner quadrant disease are at significantly higher risk for inadequate margins of excision. These patients warrant more vigilant intraoperative attention to margin status to ensure adequate margins at the end of the first operation.

O’Sullivan MJ, Li T, Freedman G, Morrow M. The effect of multiple reexcisions on the risk of local recurrence after breast conserving surgery. Ann Surg Oncol. 2007;14:3133–40.PubMedCrossRef

Sabel MS, Rogers K, Griffith K, Jagsi R, Kleer CG, Diehl KA, et al. Residual disease after re-excision lumpectomy for close margins. J Surg Oncol. 2009;99:99–103.PubMedCrossRef

Wallace AM Daniel BL, Jeffrey SS, Birdwell RL, Nowels KW, Dirbas FM, et al. Rates of re-excision for breast cancer after magnetic resonance imaging-guided bracket wire localization. J Am Coll Surg. 2005;200:527–37.PubMedCrossRef

Melstrom LG, Melstrom KA, Wang EC, Pilewskie M, Winchester DJ. Ductal carcinoma in situ: size and resection volume predict margin status. Am J Clin Oncol. 2010;33:438–42.PubMedCrossRef

Rahusen FD, Bremers AJ, Fabry HF, van Amerongen AH, Boom RP, Meijer S. Ultrasound-guided lumpectomy of nonpalpable breast cancer versus wire-guided resection: a randomized trial. Ann Surg Oncol. 2002;9:994–8.PubMedCrossRef

Pleijhuis RG, Graafland M, de Vries J, Bart J, de Jong JS, van Dam GM. Obtaining adequate surgical margins in breast-conserving therapy for patients with early-stage breast cancer: current modalities and future directions. Ann Surg Oncol. 2009;16:2717–30.PubMedCrossRef

Carlson GW, Styblo TM, Lyles RH, Jones G, Murray DR, Staley CA, et al. The use of skin sparing mastectomy in the treatment of breast cancer: The Emory experience. Surg Oncol. 2003;12:265–9.PubMedCrossRef

Simmons RM, Fish SK, Gayle L, La Trenta GS, Swistel A, Christos P, et al. Local and distant recurrence rates in skin-sparing mastectomies compared with non-skin sparing mastectomies. Ann Surg Oncol. 1999;6:676–81.PubMedCrossRef

Vaughan A, Dietz J, Aft R, Gillanders WE, Eberlein TJ, Freer P, et al. Patterns of local breast cancer recurrence after skin-sparing mastectomy and immediate breast reconstruction. Am J of Surg. 2007;194:438–43.CrossRef

10.

Munhoz AM, Montag E, Arruda E, Aldrighi CM, Filassi JR, Piato JR, et al. Immediate reconstruction following breast-conserving surgery: management of the positive surgical margins and influence on secondary reconstruction. Breast. 2009;18:47–54.PubMedCrossRef

11.

Carlson G, Page A, Johnson E, Nicholson K, Styblo TM, Wood WC. Local recurrence of ductal carcinoma in situ after skin sparing mastectomy. J Am Coll Surg. 2007;204:1074–8.PubMedCrossRef

12.

Garwood ER, Moore D, Ewing C, Hwang ES, Alvarado M, Foster RD, et al. Total skin sparing mastectomy complications and local recurrence rates in 2 cohorts of patients. Ann Surg. 2009;249:26–32.PubMedCrossRef

13.

Lindford AJ, Meretoja TJ, von Smitten KAJ, Jahkola TA. Skin-sparing mastectomy and immediate breast reconstruction in the management of locally recurrent breast cancer. Ann Surg Oncol. 2010;17:1669–74.PubMedCrossRef

14.

Rubio IT, Mirza NM, Sahin AA, Whitman G, Kroll SS, Ames FC, et al. Role of specimen radiography in patients treated with skin-sparing mastectomy for ductal carcinoma in situ of the breast. Ann Surg Oncol. 2000;7:544–8.PubMedCrossRef

15.

Rashtian A, Iganej S, Liu IA, Natarajan S. Close or positive margins after mastectomy for DCIS: pattern of relapse and potential indications for radiotherapy. Int J Rad Oncol Biol Phys. 2008;4:1016–20.

16.

Cao D, Tsangaris TN, Kouprina N, Wu LS, Balch CM, Vang R, et al. The superficial margin of skin-sparing mastectomy for breast carcinoma: factors predicting involvement and efficacy of additional margin sampling. Ann Surg Oncol. 2008;15:1330–40.PubMedCrossRef

17.

Paepke S, Schmid R, Fleckner S, Paepke D, Niemeyer M, Schmalfeldt B, et al. Subcutaneous mastectomy with preservation of the nipple-areola skin: Broadening the indications. Ann Surg. 2009;250:288–92.PubMedCrossRef

18.

Lovrics PL, Cornacchi SD, Farrokhyar F, Garnett A, Chen V, Franic S, et al. The relationship between surgical factors and margin status after breast-conservation surgery for early stage breast cancer. Am J Surg. 2009;197:740–6.PubMedCrossRef

19.

Langstein HN, Cheng MH, Singletary SE, Robb GL, Hoy E, et al. Breast cancer recurrence after immediate reconstruction: patterns and significance. Plast Reconstr Surg. 2003;111:712–20.PubMedCrossRef

Title: Inadequate Margins of Excision When Undergoing Mastectomy for Breast Cancer: Which Patients are at Risk?
Authors: Fariha Sheikh, MD
Alanna Rebecca, MD
Barbara Pockaj, MD
Nabil Wasif, MD
Ann E. McCullough, MD
William Casey, MD
Peter Kreymerman, MD
Richard J. Gray, MD
Publication date: 01-04-2011
Publisher: Springer-Verlag
Published in: Annals of Surgical Oncology / Issue 4/2011
Print ISSN: 1068-9265
Electronic ISSN: 1534-4681
DOI: https://doi.org/10.1245/s10434-010-1406-4

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Inadequate Margins of Excision When Undergoing Mastectomy for Breast Cancer: Which Patients are at Risk?

Abstract

Background

Materials and Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Materials and Methods

Results

Conclusions

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