nach oben

Erschienen in:

01.04.2007

Role for Intraoperative Margin Assessment in Patients Undergoing Breast-Conserving Surgery

verfasst von: Neslihan Cabioglu, MD, PhD, Kelly K. Hunt, MD, Aysegul A. Sahin, MD, Henry M. Kuerer, MD, PhD, Gildy V. Babiera, MD, S. Eva Singletary, MD, Gary J. Whitman, MD, Merrick I. Ross, MD, Frederick C. Ames, MD, Barry W. Feig, MD, Thomas A. Buchholz, MD, Funda Meric-Bernstam, MD

Erschienen in: Annals of Surgical Oncology | Ausgabe 4/2007

Einloggen, um Zugang zu erhalten

Abstract

Background

Positive/close margins are associated with higher in-breast failure rates after breast-conserving surgery (BCS). We investigated whether intraoperative margin assessment aids in obtaining negative margins, and to evaluate the local control thus achieved.

Methods

Between 1994 and 1996, 264 patients underwent BCS for stages 0–III breast cancer [invasive, n = 200; ductal carcinoma in situ (DCIS), n = 64]. Intraoperative margin assessment included gross tissue inspection, specimen radiography, with or without frozen section.

Results

Ninety-two patients (46%) with invasive cancer and 24 (38%) with DCIS had positive/close margins on the permanent section analysis of their initial surgical specimens. Fifty-eight patients (29%) with invasive cancer and six (9%) with DCIS had initial positive/close margins, and were rendered margin-negative by intraoperative analysis and immediate re-excision. Final margins on permanent pathology were positive/close in 52 patients (20%): 34 patients (17%) with invasive cancer and 18 patients (28%) with DCIS. By multivariate analysis, excisional biopsy for diagnosis, larger tumor size, and multifocality were associated with final positive/close margins. Of these 52 patients, 23 underwent a second operation to achieve widely negative margins (13 completion mastectomies, 10 re-excisions). The 5-year ipsilateral breast recurrence-free survival rates after BCS and radiation were 99% for invasive cancer (n = 167) and 100% for DCIS (n = 27).

Conclusions

Intraoperative assessment of margins assisted in identifying positive/close margins and allowed over a quarter of the patients to be rendered margin-negative with intraoperative re-excision at their original operation. This approach resulted in excellent local control in patients treated with BCS and radiation.

Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 2002; 347:1233–41PubMedCrossRef

Veronesi U, Cascinelli N, Mariani L, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med 2002; 347:1227–32PubMedCrossRef

Blichert-Toft M, Rose C, Andersen JA, et al. Danish randomized trial comparing breast conservation therapy with mastectomy: six years of life-table analysis. Danish Breast Cancer Cooperative Group. J Natl Cancer Inst Monogr 1992; 11:19–25PubMed

Arriagada R, Le MG, Rochard F, Contesso G. Conservative treatment versus mastectomy in early breast cancer: patterns of failure with 15 years of follow-up data. Institut Gustave-Roussy Breast Cancer Group. J Clin Oncol 1996; 14:1558–64PubMed

van Dongen JA, Voogd AC, Fentiman IS, et al. Long-term results of a randomized trial comparing breast-conserving therapy with mastectomy: European Organization for Research and Treatment of Cancer 10801 trial. J Natl Cancer Inst 2000; 92:1143–50PubMedCrossRef

Jacobson JA, Danforth DN, Cowan KH, et al. Ten-year results of a comparison of conservation with mastectomy in the treatment of stage I and II breast cancer. N Engl J Med 1995; 332:907–11PubMedCrossRef

Haffty BG, Reiss M, Beinfield M, et al. Ipsilateral breast tumor recurrence as a predictor of distant disease: implications for systemic therapy at the time of local relapse. J Clin Oncol 1996; 14:52–7PubMed

Elkhuizen PH, van de Vijver MJ, Hermans J, et al. Local recurrence after breast-conserving therapy for invasive breast cancer: high incidence in young patients and association with poor survival. Int J Radiat Oncol Biol Phys 1998; 40:859–67PubMedCrossRef

Rouzier R, Extra JM, Carton M, et al. Primary chemotherapy for operable breast cancer: incidence and prognostic significance of ipsilateral breast tumor recurrence after breast-conserving surgery. J Clin Oncol 2001; 19:3828–35PubMed

10.

Fisher ER, Anderson S, Redmond C, Fisher B. Ipsilateral breast tumor recurrence and survival following lumpectomy and irradiation: pathological findings from NSABP protocol B-06. Semin Surg Oncol 1992; 8:161–6PubMed

11.

Meric F, Mirza NQ, Vlastos G, et al. Positive surgical margins and ipsilateral breast tumor recurrence predict disease-specific survival after breast-conserving therapy. Cancer 2003; 97:926–33PubMedCrossRef

12.

Vinh-Hung V, Verschraegen C. Breast-conserving surgery with or without radiotherapy: pooled-analysis for risks of ipsilateral breast tumor recurrence and mortality. J Natl Cancer Inst 2004; 96:115–21PubMedCrossRef

13.

Group EBCTC. Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet 2005; 366:2087–106

14.

Schnitt SJ, Abner A, Gelman R, et al. The relationship between microscopic margins of resection and the risk of local recurrence in patients with breast cancer treated with breast-conserving surgery and radiation therapy. Cancer 1994; 74:1746–51PubMedCrossRef

15.

Smitt MC, Nowels KW, Zdeblick MJ, et al. The importance of the lumpectomy surgical margin status in long-term results of breast conservation. Cancer 1995; 76:259–67PubMedCrossRef

16.

Smitt MC, Nowels K, Carlson RW, Jeffrey SS. Predictors of re-excision findings and recurrence after breast conservation. Int J Radiat Oncol Biol Phys 2003; 57:979–85PubMedCrossRef

17.

Leong C, Boyages J, Jayasinghe UW, et al. Effect of margins on ipsilateral breast tumor recurrence after breast conservation therapy for lymph node-negative breast carcinoma. Cancer 2004; 100:1823–32PubMedCrossRef

18.

Gwin JL, Eisenberg BL, Hoffman JP, et al. Incidence of gross and microscopic carcinoma in specimens from patients with breast cancer after re-excision lumpectomy. Ann Surg 1993; 218:729–34PubMedCrossRef

19.

Kearney TJ, Morrow M. Effect of re-excision on the success of breast-conserving surgery. Ann Surg Oncol 1995; 2:303–7PubMedCrossRef

20.

Papa MZ, Zippel D, Koller M, et al. Positive margins of breast biopsy: is re-excision always necessary? J Surg Oncol 1999; 70:167–71PubMedCrossRef

21.

Ratanawichitrasin A, Rybicki LA, Steiger E, et al. Predicting the likelihood of residual disease in women treated for ductal carcinoma in situ. J Am Coll Surg 1999; 188:17–21PubMedCrossRef

22.

Miller AR, Brandao G, Prihoda TJ, et al. Positive margins following surgical resection of breast carcinoma: analysis of pathologic correlates. J Surg Oncol 2004; 86:134–40PubMedCrossRef

23.

Wazer DE, DiPetrillo T, Schmidt-Ullrich R, et al. Factors influencing cosmetic outcome and complication risk after conservative surgery and radiotherapy for early-stage breast carcinoma. J Clin Oncol 1992; 10:356–63PubMed

24.

Ishida T, Furuta A, Moriya T, Ohuchi N. Pathological assessment of intraductal spread of carcinoma in relation to surgical margin state in breast-conserving surgery. Jpn J Clin Oncol 2003; 33:161–6PubMedCrossRef

25.

Schnitt SJ, Connolly JL. Processing and evaluation of breast excision specimens. A clinically oriented approach. Am J Clin Pathol 1992; 98:125–37PubMed

26.

Weber S, Storm FK, Stitt J, Mahvi DM. The role of frozen section analysis of margins during breast conservation surgery. Cancer J Sci Am 1997; 3:273–7PubMed

27.

Noguchi M, Minami M, Earashi M, et al. Pathologic assessment of surgical margins on frozen and permanent sections in breast conserving surgery. Breast Cancer 1995; 2:27–33PubMedCrossRef

28.

Sauter ER, Hoffman JP, Ottery FD, et al. Is frozen section analysis of re-excision lumpectomy margins worthwhile? Margin analysis in breast re-excisions. Cancer 1994; 73:2607–12PubMedCrossRef

29.

Cendan JC, Coco D, Copeland EM III. Accuracy of intraoperative frozen-section analysis of breast cancer lumpectomy-bed margins. J Am Coll Surg 2005; 201:194–8PubMedCrossRef

30.

Klimberg VS, Westbrook KC, Korourian S. Use of touch preps for diagnosis and evaluation of surgical margins in breast cancer. Ann Surg Oncol 1998; 5:220–6PubMedCrossRef

31.

Cox CE, Hyacinthe M, Gonzalez RJ, et al. Cytologic evaluation of lumpectomy margins in patients with ductal carcinoma in situ: clinical outcome. Ann Surg Oncol 1997; 4:644–9PubMedCrossRef

32.

Cox CE, Pendas S, Ku NN, et al. Local recurrence of breast cancer after cytological evaluation of lumpectomy margins. Am Surg 1998; 64:533–7; discussion 7–8

33.

Creager AJ, Shaw JA, Young PR, Geisinger KR. Intraoperative evaluation of lumpectomy margins by imprint cytology with histologic correlation: a community hospital experience. Arch Pathol Lab Med 2002; 126:846–8PubMed

34.

Greene FL, Page DL, Fleming ID, eds. et al. (2002) Breast. AJCC Cancer Staging Manual, 6th ed. New York: Springer pp 223–40

35.

Sahin A. (2004) Surgical margin evaluation in patients treated with breast-conserving therapy. In: Singletary SE, Robb GL, Hortobagyi GN, eds. Advanced therapy of breast disease, 2nd edn. Ontario: BC Decker, Inc., pp 341–84

36.

Camp ER, McAuliffe PF, Gilroy JS, et al. Minimizing local recurrence after breast conserving therapy using intraoperative shaved margins to determine pathologic tumor clearance. J Am Coll Surg 2005; 201:855–61PubMedCrossRef

37.

Lagios MD. (2002) Practical pathology of ductal carcinoma in situ: how to derive optimal data from the pathologic examination. In: Silverstein MJ, Recht A, Lagios MD, eds. Ductal carcinoma in situ of the breast, 2nd ed. Philadelphia: Lippincott Williams & Wilkins; pp 207–21

38.

Oakley KL, Going JJ. Specimen slice radiography of cancer in breast conserving excisions. J Clin Pathol 1995; 48:1028–30PubMed

39.

Rubio IT, Mirza N, Sahin AA, 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; 7:544–8PubMedCrossRef

40.

Chagpar A, Yen T, Sahin A, et al. Intraoperative margin assessment reduces re-excision rates in patients with ductal carcinoma in situ treated with breast-conserving surgery. Am J Surg 2003; 186:371–7PubMedCrossRef

41.

McCormick JT, Keleher AJ, Tikhomirov VB, et al. Analysis of the use of specimen mammography in breast conservation therapy. Am J Surg 2004; 188:433–6PubMedCrossRef

42.

Obedian E, Haffty BG. Negative margin status improves local control in conservatively managed breast cancer patients. Cancer J Sci Am 2000; 6:28–33PubMed

43.

Tartter PI, Kaplan J, Bleiweiss I, et al. Lumpectomy margins, re-excision, and local recurrence of breast cancer. Am J Surg 2000; 179:81–5PubMedCrossRef

44.

Park CC, Mitsumori M, Nixon A, et al. Outcome at 8 years after breast-conserving surgery and radiation therapy for invasive breast cancer: influence of margin status and systemic therapy on local recurrence. J Clin Oncol 2000; 18:1668–75PubMed

45.

Luu HH, Otis CN, Reed WP Jr, et al. The unsatisfactory margin in breast cancer surgery. Am J Surg 1999; 178:362–6PubMedCrossRef

46.

Chagpar AB, Martin RC II, Hagendoorn LJ, et al. Lumpectomy margins are affected by tumor size and histologic subtype but not by biopsy technique. Am J Surg 2004; 188:399–402PubMedCrossRef

47.

Saarela AO, Rissanen TJ, Lahteenmaki KM, et al. Wire-guided excision of non-palpable breast cancer: determinants and correlations between radiologic and histologic margins and residual disease in re-excisions. Breast 2001; 10:28–34PubMedCrossRef

48.

Singletary SE. Surgical margins in patients with early-stage breast cancer treated with breast conservation therapy. Am J Surg 2002; 184:383–93PubMedCrossRef

49.

Cabioglu N, Hunt KK, Buchholz TA, et al. Improving local control with breast-conserving therapy: a 27-year single-institution experience. Cancer 2005; 104:20–9PubMedCrossRef

50.

Weinberg E, Cox C, Dupont E, et al. Local recurrence in lumpectomy patients after imprint cytology margin evaluation. Am J Surg 2004; 188:349–54PubMedCrossRef

51.

Buchholz TA, Tucker SL, Erwin J, et al. Impact of systemic treatment on local control for patients with lymph node-negative breast cancer treated with breast-conservation therapy. J Clin Oncol 2001; 19:2240–6PubMed

Titel: Role for Intraoperative Margin Assessment in Patients Undergoing Breast-Conserving Surgery
verfasst von: Neslihan Cabioglu, MD, PhD
Kelly K. Hunt, MD
Aysegul A. Sahin, MD
Henry M. Kuerer, MD, PhD
Gildy V. Babiera, MD
S. Eva Singletary, MD
Gary J. Whitman, MD
Merrick I. Ross, MD
Frederick C. Ames, MD
Barry W. Feig, MD
Thomas A. Buchholz, MD
Funda Meric-Bernstam, MD
Publikationsdatum: 01.04.2007
Verlag: Springer-Verlag
Erschienen in: Annals of Surgical Oncology / Ausgabe 4/2007
Print ISSN: 1068-9265
Elektronische ISSN: 1534-4681
DOI: https://doi.org/10.1245/s10434-006-9236-0

Neu im Fachgebiet Chirurgie

Mehr Frauen im OP – weniger postoperative Komplikationen

21.05.2024 Allgemeine Chirurgie Nachrichten

Ein Frauenanteil von mindestens einem Drittel im ärztlichen Op.-Team war in einer großen retrospektiven Studie aus Kanada mit einer signifikanten Reduktion der postoperativen Morbidität assoziiert.

„Übersichtlicher Wegweiser“: Lauterbachs umstrittener Klinik-Atlas ist online

17.05.2024 Klinik aktuell Nachrichten

Sie sei „ethisch geboten“, meint Gesundheitsminister Karl Lauterbach: mehr Transparenz über die Qualität von Klinikbehandlungen. Um sie abzubilden, lässt er gegen den Widerstand vieler Länder einen virtuellen Klinik-Atlas freischalten.

Was nützt die Kraniektomie bei schwerer tiefer Hirnblutung?

17.05.2024 Hirnblutung Nachrichten

Eine Studie zum Nutzen der druckentlastenden Kraniektomie nach schwerer tiefer supratentorieller Hirnblutung deutet einen Nutzen der Operation an. Für überlebende Patienten ist das dennoch nur eine bedingt gute Nachricht.

Klinikreform soll zehntausende Menschenleben retten

15.05.2024 Klinik aktuell Nachrichten

Gesundheitsminister Lauterbach hat die vom Bundeskabinett beschlossene Klinikreform verteidigt. Kritik an den Plänen kommt vom Marburger Bund. Und in den Ländern wird über den Gang zum Vermittlungsausschuss spekuliert.

Update Chirurgie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.

Newsletter bestellen

Aktuelle BDC Leitlinien-Webinare

S3-Leitlinie „Diagnostik und Therapie des Karpaltunnelsyndroms“

Karpaltunnelsyndrom BDC Leitlinien Webinare

CME: 2 Punkte

Das Karpaltunnelsyndrom ist die häufigste Kompressionsneuropathie peripherer Nerven. Obwohl die Anamnese mit dem nächtlichen Einschlafen der Hand (Brachialgia parästhetica nocturna) sehr typisch ist, ist eine klinisch-neurologische Untersuchung und Elektroneurografie in manchen Fällen auch eine Neurosonografie erforderlich. Im Anfangsstadium sind konservative Maßnahmen (Handgelenksschiene, Ergotherapie) empfehlenswert. Bei nicht Ansprechen der konservativen Therapie oder Auftreten von neurologischen Ausfällen ist eine Dekompression des N. medianus am Karpaltunnel indiziert.

Prof. Dr. med. Gregor Antoniadis

S2e-Leitlinie „Distale Radiusfraktur“

Radiusfraktur BDC Leitlinien Webinare

CME: 2 Punkte

Das Webinar beschäftigt sich mit Fragen und Antworten zu Diagnostik und Klassifikation sowie Möglichkeiten des Ausschlusses von Zusatzverletzungen. Die Referenten erläutern, welche Frakturen konservativ behandelt werden können und wie. Das Webinar beantwortet die Frage nach aktuellen operativen Therapiekonzepten: Welcher Zugang, welches Osteosynthesematerial? Auf was muss bei der Nachbehandlung der distalen Radiusfraktur geachtet werden?

PD Dr. med. Oliver Pieske

Dr. med. Benjamin Meyknecht

S1-Leitlinie „Empfehlungen zur Therapie der akuten Appendizitis bei Erwachsenen“

Appendizitis BDC Leitlinien Webinare

CME: 2 Punkte

Inhalte des Webinars zur S1-Leitlinie „Empfehlungen zur Therapie der akuten Appendizitis bei Erwachsenen“ sind die Darstellung des Projektes und des Erstellungswegs zur S1-Leitlinie, die Erläuterung der klinischen Relevanz der Klassifikation EAES 2015, die wissenschaftliche Begründung der wichtigsten Empfehlungen und die Darstellung stadiengerechter Therapieoptionen.

Dr. med. Mihailo Andric

Die Highlights vom Kongress des American College of Cardiology 2024

Springer Medizin

Role for Intraoperative Margin Assessment in Patients Undergoing Breast-Conserving Surgery