- Email: [email protected]
Do additional shaved margins at the time of lumpectomy eliminate the need for re-excision?
The American Journal of Surgery (2008) 196, 556 –558
The American Society of Breast Surgeons
Do additional shaved margins at the time of lumpectomy eliminate the need for re-excision? Allyson F. Jacobson, M.D.a, Juhi Asad, D.O.a, Susan K. Boolbol, M.D.a,*, Michael P. Osborne, M.D.a, Kwadwo Boachie-Adjei, M.Ph.b, Sheldon M. Feldman, M.D.a a
Department of General Surgery, Division of Breast Surgery, Beth Israel Medical Center, 10 Union Square East, Ste 4E, New York, NY 10003, USA; bDepartment of Surgical Oncology-Research, Beth Israel Medical Center, New York, NY, USA KEYWORDS: Shaved margins; Lumpectomy; Breast conservation; Breast cancer; Re-excision
Abstract BACKGROUND: Most women diagnosed with breast cancer undergo breast-conservation surgery. Re-excision rates for positive margins have been reported to be greater than 50%. The purpose of our study was to determine if removing additional shaved margins from the lumpectomy cavity at the time of lumpectomy reduces re-excisions. METHODS: A retrospective study was performed on 125 women who had undergone lumpectomy with additional shaved margins taken from the lumpectomy cavity. Pathology reports were reviewed for tumor size and histology, lumpectomy and additional margin status, and specimen and margin volume. RESULTS: If additional margins were not taken, 66% would have required re-excision. Because of taking additional shaved margins, re-excision was eliminated in 48%. CONCLUSION: Excising additional shaved margins at the original surgery reduced reoperations by 48%. There is a balance between removing additional margins and desirable cosmesis after breastconservation surgery. The decision to take extra margins should be based on the surgeon’s judgment. © 2008 Published by Elsevier Inc.
Breast conservation has become the most commonly performed surgery for breast cancer treatment. Randomized trials have shown that overall survival of women undergoing breast-conservation surgery with adjuvant radiation therapy is equivalent to mastectomy.1,2 The main goal for breast-conservation surgery is complete excision of the tumor with adequate margins while maintaining acceptable cosmesis. Margins microscopically clear of tumor are essential to minimize the risk of local recurrence.3,4 It is not uncommon to have residual cancer at or near the margins where re-excision would be * Corresponding author. Tel.: ⫹212-844-6231; fax: ⫹212-844-8954. E-mail address: [email protected] Manuscript received April 16, 2008; revised manuscript June 1, 2008
0002-9610/$ - see front matter © 2008 Published by Elsevier Inc. doi:10.1016/j.amjsurg.2008.06.007
recommended. In the literature, the rate for re-excision has been reported to be greater than 50%.5,6 Multiple excisions increase morbidity and affect cosmesis. Reoperation also causes undue stress on the patient as well as additional costs. When re-excision of margins is performed at the time of lumpectomy after the specimen is removed, this is referred to as shaved cavity margins. These shaved margins are a sampling of each cavity wall, and, being surgeon dependent, the volume removed is variable. When reviewing the literature, this approach has not been extensively described. Our study was performed to determine if removing additional shaved margins from the lumpectomy cavity at the time of the original surgery reduced the need for re-excision.
A.F. Jacobson et al.
Shaved lumpectomy margins eliminate re-excision
Methods A retrospective study was performed by using an institutional review board–approved database at Beth Israel Medical Center (New York, NY). After obtaining separate institutional review board approval for this study, the pathology results were reviewed for 125 women who had undergone a lumpectomy between September 2002 and October 2006. Additional shaved cavity margins were obtained in all patients at the time of the original surgery. The shaved margins were excised from the walls of the lumpectomy cavity after the original specimen had been removed. Most patients had all 6 cavity margins re-excised (superior, inferior, medial, and lateral plus/minus anterior and posterior) based on the extent of the original excision. The lumpectomy specimens were oriented by using a short suture marking the superior margin and a long suture marking the lateral margin. Each separate additional shaved margin was labeled with a suture at the new margin. All pathology reports were reviewed, and the following information was collected (Table 1): tumor size, tumor and margin histology, margin status of lumpectomy and additional margins (negative or positive, defined as tumor ⱕ2mm from inked margin), volume of lumpectomy and margins, presence of lymphovascular invasion, and nodal status. Our shaved margins were evaluated in the same fashion as the original lumpectomy specimen margins, with the tumor identified within a given distance from the margins. Also included were the patients who required additional surgery to achieve negative margins. The statistical analysis was performed with the Stata Software (College Station, TX USA) for Windows.
Results One hundred twenty-five patients underwent lumpectomy with excision of additional shaved margins at the time of initial surgery. The average tumor size was 1.8 cm (range
Table 1
Patient and tumor characteristics
Age ⬍50 ⬎50 Tumor size DCIS T1 T2 LVI Yes No Pathologic LN status Negative Positive Unknown
No.
%
41 84
33 67
26 66 33
21 53 26
43 82
34 66
74 35 16
59 28 13
557
Table 2 Margin status of lumpectomy specimens and additional shaved margins (N ⫽ 125) LM⫺ SM⫺
LM⫹ SM⫺
LM⫹ SM⫹
LM⫺ SM⫹
41 (33%)
61 (49%)
22 (18%)
1 (1%)
LM ⫽ lumpectomy margin; SM ⫽ shaved margin.
0.3–5 cm). The median volume of the lumpectomy specimens was 44 cm3 (range 3.25– 484.5 cm3). The median volume of additional shaved margins was 24 cm3 (range 2.0 –94.5 cm3). The relationship between tumor size and margin status was not statistically significant (P ⫽ .1). Because of the wide range of specimen volumes, no correlation could be made between lumpectomy volume and margin volume. Of the 125 lumpectomy specimens, 66% (n ⫽ 83) had at least 1 positive margin, and 34% (n ⫽ 42) had all negative margins. For nearly half of the patients, a second surgery was eliminated because of the excision of additional margins (Table 2). For 50% (n ⫽ 63) of patients, excision of additional margins did not change management. In this group of patients in whom shaved margins did not alter management, 33% (n ⫽ 41) of the lumpectomy margins were initially negative, and for 18% (n ⫽ 22) the margins remained positive even after excising shaved margins. If additional margins were not taken at the time of lumpectomy, 66% (n ⫽ 83) of patients would have required a re-excision. Nine patients ultimately required mastectomy to achieve negative margins; for 6, mastectomy was their second surgery, and for 3 the mastectomy was after positive margins persisted after re-excision. One patient had negative lumpectomy margins and a positive shaved cavity margin, therefore requiring re-excision to achieve negative margins. Table 3 shows the correlation between tumor histology and positive margins. For tumors that are pure invasive ductal carcinoma (IDC), 27% (4/15) had positive margins. When IDC was found with ductal carcinoma in situ (DCIS), 65% (44/68) of tumors had positive margins; for mixed invasive ductal and invasive lobular carcinoma (ILC), 100% (3/3) had positive margins. Ninety-two percent (24/26) of
Table 3 Correlation between margin positivity and tumor pathology (N ⫽ 125) IDC/ IDC/ IDC/ILC DCIS IDC DCIS ILC ILC DCIS Other No. of tumors 26 No. of positive lumpectomy margins 24 No. of positive shaved margins 9
15
68
5
3
5
3
4
44
4
3
3
1
0
8
3
0
0
1
558 pure DCIS and 80% (4/5) of pure ILC had positive margins. Whether DCIS was alone or found with invasive carcinoma, margins were 86% more likely to be positive than with pure IDC (odds ratio 0.14; 95% confidence interval, 0.03– 0.55). When ILC was alone or involved, the margins were 95% more likely to be positive than pure IDC (odds ratio 0.05; 95% confidence interval, 0.001– 0.69). The relationship between lymphovascular invasion and margin positivity was not significant (P ⫽ .33).
Comments One goal of breast-conservation surgery is a complete tumor resection with adequate margins to minimize risk of recurrence. In our study, excising additional shaved cavity margins at the time of lumpectomy reduced the re-excision rate for 49% of cases. Our results support those by Cao et al5 who looked at 126 women undergoing lumpectomy with additional shaved cavity margins. This study concluded that reoperation was avoided in 59% of patients by removing additional shaved margins. Other studies7,8 have shown that there is a high rate of margin positivity when tumors have components of ductal carcinoma in situ as well as invasive lobular carcinoma. Our study shows similar results; in addition, by taking additional margins from these groups of patients, the rate of re-excision was reduced. If adequate preoperative tissue sampling is performed and a diagnosis is established, this may aid surgeons in selectively choosing which patients may benefit from obtaining additional shaved margins. An important aspect of breast-conservation surgery after a sound oncologic operation is the cosmetic result. The volume of the lumpectomy specimen removed is a decision made by the surgeon based on the relationship between estimated tumor and breast size. Our study showed no statistical correlation between tumor size and positive margins, but there was no analyzable data recorded about individual patient breast size. With each individual patient, the surgeon must decide how to offer the best cosmetic result while obtaining clear margins. Options include re-excising more tissue at the time of initial surgery versus taking the risk of performing additional operations. It has been debated whether removing a larger lumpectomy specimen, instead of taking extra separate margins, would achieve the same result. Most surgeons probably initially remove what they feel is an adequate rim of normal tissue around the specimen. Instead, the tumor removed is often found to be not at the center of the specimen but close to or involving 1 or more margins. This results in a large number of cases in which there are close or positive margins requiring re-excision. Removing shaved margins allows additional targeted volume excision based on intraoperative
The American Journal of Surgery, Vol 196, No 4, October 2008 evaluation. After the lumpectomy is removed and assessed by specimen radiograph and/or palpation, the location of the tumor in relation to the margins can direct shaved margin excision. It can be argued that excising shaved margins is cavity sampling and not a complete excision of the cavity wall. Sampling of the cavity estimates whether there is residual disease present at the margin. What we do not know is how much disease can safely be left behind and still maintain a low recurrence risk. Many studies revealed that even when no residual disease was found, women undergoing breastconserving surgery benefited from the addition of radiation therapy and experience a 20% to 30% decrease in local recurrence.1,9 In our patient population, no local recurrences have occurred to date, but it has been too short a time for follow up to state any meaningful conclusions. However, there is a balance to removing more tissue for additional margins and still having a desirable cosmetic outcome after breast-conservation surgery. The choice to take extra margins should be based on the surgeon’s judgment, incorporating tumor size, breast size, and histology into the ultimate decision.
References 1. 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– 41. 2. 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;347:1227–32. 3. Gage I, Schnitt S, Nixon A, et al. Pathologic margin involvement and the risk of recurrence in patients treated with breast-conserving therapy. Cancer 1996;78:1921– 8. 4. Schnitt S, 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 –51. 5. Cao D, Lin C, Woo SH, et al. Separate cavity margin sampling at the time of initial breast lumpectomy significantly reduces the need for reexcision. Am J Surg Pathol 2005;29:1625–32. 6. Huston T, Pigalarga R, Osborne M, Tousimis E. The influence of additional surgical margins on the total specimen volume excised and the reoperative rate after breast-conserving surgery. Am J Surg 2006; 192:509 –12. 7. Keskek M, Kothari M, Ardehali B, et al. Factors predisposing to cavity margin positivity following conservation surgery for breast cancer. Eur J Surg Oncol 2004;30:1058 – 64. 8. O’Sullivan M, Li T, Freedman, Morrow M. The effect of multiple reexcisions on the risk of local recurrence after breast conserving surgery. Ann Surg Oncol 2007;14:3133– 40. 9. Early Breast Cancer Trialists’ Collaborative Group. 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 randomized trials. Lancet 2005;366:2087–106.
The American Society of Breast Surgeons
Do additional shaved margins at the time of lumpectomy eliminate the need for re-excision? Allyson F. Jacobson, M.D.a, Juhi Asad, D.O.a, Susan K. Boolbol, M.D.a,*, Michael P. Osborne, M.D.a, Kwadwo Boachie-Adjei, M.Ph.b, Sheldon M. Feldman, M.D.a a
Department of General Surgery, Division of Breast Surgery, Beth Israel Medical Center, 10 Union Square East, Ste 4E, New York, NY 10003, USA; bDepartment of Surgical Oncology-Research, Beth Israel Medical Center, New York, NY, USA KEYWORDS: Shaved margins; Lumpectomy; Breast conservation; Breast cancer; Re-excision
Abstract BACKGROUND: Most women diagnosed with breast cancer undergo breast-conservation surgery. Re-excision rates for positive margins have been reported to be greater than 50%. The purpose of our study was to determine if removing additional shaved margins from the lumpectomy cavity at the time of lumpectomy reduces re-excisions. METHODS: A retrospective study was performed on 125 women who had undergone lumpectomy with additional shaved margins taken from the lumpectomy cavity. Pathology reports were reviewed for tumor size and histology, lumpectomy and additional margin status, and specimen and margin volume. RESULTS: If additional margins were not taken, 66% would have required re-excision. Because of taking additional shaved margins, re-excision was eliminated in 48%. CONCLUSION: Excising additional shaved margins at the original surgery reduced reoperations by 48%. There is a balance between removing additional margins and desirable cosmesis after breastconservation surgery. The decision to take extra margins should be based on the surgeon’s judgment. © 2008 Published by Elsevier Inc.
Breast conservation has become the most commonly performed surgery for breast cancer treatment. Randomized trials have shown that overall survival of women undergoing breast-conservation surgery with adjuvant radiation therapy is equivalent to mastectomy.1,2 The main goal for breast-conservation surgery is complete excision of the tumor with adequate margins while maintaining acceptable cosmesis. Margins microscopically clear of tumor are essential to minimize the risk of local recurrence.3,4 It is not uncommon to have residual cancer at or near the margins where re-excision would be * Corresponding author. Tel.: ⫹212-844-6231; fax: ⫹212-844-8954. E-mail address: [email protected] Manuscript received April 16, 2008; revised manuscript June 1, 2008
0002-9610/$ - see front matter © 2008 Published by Elsevier Inc. doi:10.1016/j.amjsurg.2008.06.007
recommended. In the literature, the rate for re-excision has been reported to be greater than 50%.5,6 Multiple excisions increase morbidity and affect cosmesis. Reoperation also causes undue stress on the patient as well as additional costs. When re-excision of margins is performed at the time of lumpectomy after the specimen is removed, this is referred to as shaved cavity margins. These shaved margins are a sampling of each cavity wall, and, being surgeon dependent, the volume removed is variable. When reviewing the literature, this approach has not been extensively described. Our study was performed to determine if removing additional shaved margins from the lumpectomy cavity at the time of the original surgery reduced the need for re-excision.
A.F. Jacobson et al.
Shaved lumpectomy margins eliminate re-excision
Methods A retrospective study was performed by using an institutional review board–approved database at Beth Israel Medical Center (New York, NY). After obtaining separate institutional review board approval for this study, the pathology results were reviewed for 125 women who had undergone a lumpectomy between September 2002 and October 2006. Additional shaved cavity margins were obtained in all patients at the time of the original surgery. The shaved margins were excised from the walls of the lumpectomy cavity after the original specimen had been removed. Most patients had all 6 cavity margins re-excised (superior, inferior, medial, and lateral plus/minus anterior and posterior) based on the extent of the original excision. The lumpectomy specimens were oriented by using a short suture marking the superior margin and a long suture marking the lateral margin. Each separate additional shaved margin was labeled with a suture at the new margin. All pathology reports were reviewed, and the following information was collected (Table 1): tumor size, tumor and margin histology, margin status of lumpectomy and additional margins (negative or positive, defined as tumor ⱕ2mm from inked margin), volume of lumpectomy and margins, presence of lymphovascular invasion, and nodal status. Our shaved margins were evaluated in the same fashion as the original lumpectomy specimen margins, with the tumor identified within a given distance from the margins. Also included were the patients who required additional surgery to achieve negative margins. The statistical analysis was performed with the Stata Software (College Station, TX USA) for Windows.
Results One hundred twenty-five patients underwent lumpectomy with excision of additional shaved margins at the time of initial surgery. The average tumor size was 1.8 cm (range
Table 1
Patient and tumor characteristics
Age ⬍50 ⬎50 Tumor size DCIS T1 T2 LVI Yes No Pathologic LN status Negative Positive Unknown
No.
%
41 84
33 67
26 66 33
21 53 26
43 82
34 66
74 35 16
59 28 13
557
Table 2 Margin status of lumpectomy specimens and additional shaved margins (N ⫽ 125) LM⫺ SM⫺
LM⫹ SM⫺
LM⫹ SM⫹
LM⫺ SM⫹
41 (33%)
61 (49%)
22 (18%)
1 (1%)
LM ⫽ lumpectomy margin; SM ⫽ shaved margin.
0.3–5 cm). The median volume of the lumpectomy specimens was 44 cm3 (range 3.25– 484.5 cm3). The median volume of additional shaved margins was 24 cm3 (range 2.0 –94.5 cm3). The relationship between tumor size and margin status was not statistically significant (P ⫽ .1). Because of the wide range of specimen volumes, no correlation could be made between lumpectomy volume and margin volume. Of the 125 lumpectomy specimens, 66% (n ⫽ 83) had at least 1 positive margin, and 34% (n ⫽ 42) had all negative margins. For nearly half of the patients, a second surgery was eliminated because of the excision of additional margins (Table 2). For 50% (n ⫽ 63) of patients, excision of additional margins did not change management. In this group of patients in whom shaved margins did not alter management, 33% (n ⫽ 41) of the lumpectomy margins were initially negative, and for 18% (n ⫽ 22) the margins remained positive even after excising shaved margins. If additional margins were not taken at the time of lumpectomy, 66% (n ⫽ 83) of patients would have required a re-excision. Nine patients ultimately required mastectomy to achieve negative margins; for 6, mastectomy was their second surgery, and for 3 the mastectomy was after positive margins persisted after re-excision. One patient had negative lumpectomy margins and a positive shaved cavity margin, therefore requiring re-excision to achieve negative margins. Table 3 shows the correlation between tumor histology and positive margins. For tumors that are pure invasive ductal carcinoma (IDC), 27% (4/15) had positive margins. When IDC was found with ductal carcinoma in situ (DCIS), 65% (44/68) of tumors had positive margins; for mixed invasive ductal and invasive lobular carcinoma (ILC), 100% (3/3) had positive margins. Ninety-two percent (24/26) of
Table 3 Correlation between margin positivity and tumor pathology (N ⫽ 125) IDC/ IDC/ IDC/ILC DCIS IDC DCIS ILC ILC DCIS Other No. of tumors 26 No. of positive lumpectomy margins 24 No. of positive shaved margins 9
15
68
5
3
5
3
4
44
4
3
3
1
0
8
3
0
0
1
558 pure DCIS and 80% (4/5) of pure ILC had positive margins. Whether DCIS was alone or found with invasive carcinoma, margins were 86% more likely to be positive than with pure IDC (odds ratio 0.14; 95% confidence interval, 0.03– 0.55). When ILC was alone or involved, the margins were 95% more likely to be positive than pure IDC (odds ratio 0.05; 95% confidence interval, 0.001– 0.69). The relationship between lymphovascular invasion and margin positivity was not significant (P ⫽ .33).
Comments One goal of breast-conservation surgery is a complete tumor resection with adequate margins to minimize risk of recurrence. In our study, excising additional shaved cavity margins at the time of lumpectomy reduced the re-excision rate for 49% of cases. Our results support those by Cao et al5 who looked at 126 women undergoing lumpectomy with additional shaved cavity margins. This study concluded that reoperation was avoided in 59% of patients by removing additional shaved margins. Other studies7,8 have shown that there is a high rate of margin positivity when tumors have components of ductal carcinoma in situ as well as invasive lobular carcinoma. Our study shows similar results; in addition, by taking additional margins from these groups of patients, the rate of re-excision was reduced. If adequate preoperative tissue sampling is performed and a diagnosis is established, this may aid surgeons in selectively choosing which patients may benefit from obtaining additional shaved margins. An important aspect of breast-conservation surgery after a sound oncologic operation is the cosmetic result. The volume of the lumpectomy specimen removed is a decision made by the surgeon based on the relationship between estimated tumor and breast size. Our study showed no statistical correlation between tumor size and positive margins, but there was no analyzable data recorded about individual patient breast size. With each individual patient, the surgeon must decide how to offer the best cosmetic result while obtaining clear margins. Options include re-excising more tissue at the time of initial surgery versus taking the risk of performing additional operations. It has been debated whether removing a larger lumpectomy specimen, instead of taking extra separate margins, would achieve the same result. Most surgeons probably initially remove what they feel is an adequate rim of normal tissue around the specimen. Instead, the tumor removed is often found to be not at the center of the specimen but close to or involving 1 or more margins. This results in a large number of cases in which there are close or positive margins requiring re-excision. Removing shaved margins allows additional targeted volume excision based on intraoperative
The American Journal of Surgery, Vol 196, No 4, October 2008 evaluation. After the lumpectomy is removed and assessed by specimen radiograph and/or palpation, the location of the tumor in relation to the margins can direct shaved margin excision. It can be argued that excising shaved margins is cavity sampling and not a complete excision of the cavity wall. Sampling of the cavity estimates whether there is residual disease present at the margin. What we do not know is how much disease can safely be left behind and still maintain a low recurrence risk. Many studies revealed that even when no residual disease was found, women undergoing breastconserving surgery benefited from the addition of radiation therapy and experience a 20% to 30% decrease in local recurrence.1,9 In our patient population, no local recurrences have occurred to date, but it has been too short a time for follow up to state any meaningful conclusions. However, there is a balance to removing more tissue for additional margins and still having a desirable cosmetic outcome after breast-conservation surgery. The choice to take extra margins should be based on the surgeon’s judgment, incorporating tumor size, breast size, and histology into the ultimate decision.
References 1. 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– 41. 2. 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;347:1227–32. 3. Gage I, Schnitt S, Nixon A, et al. Pathologic margin involvement and the risk of recurrence in patients treated with breast-conserving therapy. Cancer 1996;78:1921– 8. 4. Schnitt S, 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 –51. 5. Cao D, Lin C, Woo SH, et al. Separate cavity margin sampling at the time of initial breast lumpectomy significantly reduces the need for reexcision. Am J Surg Pathol 2005;29:1625–32. 6. Huston T, Pigalarga R, Osborne M, Tousimis E. The influence of additional surgical margins on the total specimen volume excised and the reoperative rate after breast-conserving surgery. Am J Surg 2006; 192:509 –12. 7. Keskek M, Kothari M, Ardehali B, et al. Factors predisposing to cavity margin positivity following conservation surgery for breast cancer. Eur J Surg Oncol 2004;30:1058 – 64. 8. O’Sullivan M, Li T, Freedman, Morrow M. The effect of multiple reexcisions on the risk of local recurrence after breast conserving surgery. Ann Surg Oncol 2007;14:3133– 40. 9. Early Breast Cancer Trialists’ Collaborative Group. 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 randomized trials. Lancet 2005;366:2087–106.