- Email: [email protected]
The Effect of Multiple Reexcisions on the Risk of Local Recurrence After Breast Conserving Surgery
tients with evidence of metastatic disease in SLNs. Molecular tests such as the BLN Assay can overcome the limitations of the currently used tests for intraoperative detection of metastatic disease in SLNs by providing results very much comparable to those of a final histolog-
ic evaluation. Using this test in conjunction with histologic evaluation rather than in isolation will probably be more prudent for its successful integration into pathology practice. Combining the 2 tests not only will provide archivable proof of metastatic disease but also will allow a more thor-
ough sampling of the lymph node. It should be noted that well-calibrated molecular tests such as the BLN Assay could be very useful for thorough evaluation of both SLNs and non-SLNs in patients with breast cancer. S. Krishnamurthy, MD
BREAST-CONSERVING THERAPY The Effect of Multiple Reexcisions on the Risk of Local Recurrence After Breast Conserving Surgery O’Sullivan MJ, Li T, Freedman G, et al (Fox Chase Cancer Ctr, Philadelphia) Ann Surg Oncol 14:3133-3140, 2007
Background.—Guidelines for breast conserving surgery (BCS) advise mastectomy if negative margins cannot be obtained after reasonable surgical attempts. This study examined the effect of multiple reexcisions on local recurrence (LR) and identified factors predictive of the need for multiple reexcisions. Methods.—2,770 patients undergoing BCS over 25 years were analyzed; 137 patients (group A) with two or more reexcisions, 1514 patients with one reexcision (group B), and 1119 patients who had no reexcision (group C). The median follow-up was 73 months. Results.—The five and ten-year actuarial LR rates for groups A, B, and C were 5.5%, 1.9%, 2.5%, and 10%, 5.7%,
and 5.6%, respectively. The number of reexcisions did not predict for LR on multivariate analysis. Women <40 years underwent reexcision more frequently than other age groups. Patients with tumors detected by palpation alone made up 14% of the reexcision group versus 8% of the no reexcision group (p <0.001). Patients with ductal carcinoma in situ and lobular carcinoma were more likely to require reexcision than those with ductal carcinoma. On multivariate analysis, younger age, detection by physical exam only, lobular histology, smaller tumor size, and the presence of extensive intraductal component (EIC) were highly significant predictors of the need for reexcision. Conclusions.—Multiple reexcisions do not impact on LR rates if negative margins are ultimately obtained. Conversion to mastectomy based solely on the number of excisions performed is not indicated. Subsets of patients more likely to require reexcision, who may be candidates for a larger initial resection, can be identified.
One of the prerequisites for successful breast-conserving surgery is negative margins, which impact LR and overall survival. In order to achieve negative margins, re-excision of the margins in the form of a directed margin excision or the entire lumpectomy cavity may be required, although the impact of re-excision on LR has not been well analyzed. A previous report by Mennes and colleagues1 reported that multiple re-excisions were associated with an increased rate of LR. This series has only 459 patients compared with the 2,770 patients in the study by O’Sullivan and colleagues. Both had overall high re-excision rates (50% and 54%, respectively) in which 5% of the patients had 2 or more re-excisions. The overall LR rate was similar between the groups (4.7% and 6.0%, respectively). Both studies demonstrated by univariate and multivariate analyses that 1 re-excision did not impact LR. On the other hand, multivariate analysis of no re-excision versus 2 reexcisions did not significantly impact
®
Breast Diseases: A Year Book Quarterly Vol 19 No 2 2008
161 161
LR in the study by O’Sullivan and colleagues (10%), whereas the earlier study by Mennes and colleagues1 (13%) did show persistent significance. The main difference between the 2 studies was their definitions of negative margin. In the O’Sullivan study, negative margin was defined as 2 mm, and in the Mennes study, it was defined as 1 mm. Overall, these studies support the use of re-excision to achieve negative margins and suggest that patients who require more than 1 negative margin should be evaluated closely to determine their next surgical option. The other important point brought up in the current article was that they
identified patients who were at high risk for re-excision. Their findings are consistent with those of other studies. An important observation by the authors was that those who need a larger reexcision should be identified preoperatively. I think there are sufficient technologies available to surgeons to decrease re-excision rates and provide better overall outcome for patients. This includes extensive preoperative evaluation, including selected use of breast magnetic resonance imaging, intraoperative localization by radioactive seed or ultrasonography, and use of intraoperative frozen-section or touch prep cytology for margins. These procedures have
been adopted by our institution, resulting in a re-excision rate of only 8%.
Patterns of local breast cancer recurrence after skin-sparing mastectomy and immediate breast reconstruction
ferences between patients who recurred and those who did not with respect to tumor size/stage, margin status, estrogen receptor/progesterone receptor/Her2neu status, lymph node metastases, or radiation therapy (P > .05). Patients with grade 3 invasive tumors or high-grade ductal carcinoma in situ were more likely to recur than patients with grade 1 or 2 invasive tumors or low- or intermediate-grade ductal carcinoma in situ (P = .0035). Those patients who recurred had a significantly decreased overall survival compared to patients who did not recur (P = .0006). Conclusions.—Skin-sparing mastectomy and immediate reconstruction has a low local recurrence rate. Recurrences occur most commonly in the same quadrant as the primary tumor and treatment approaches include surgery, chemotherapy, and radiation therapy. Local recurrence portends a poorer overall survival.
local recurrence rates in patients undergoing skin-sparing mastectomies comparable to those undergoing nonskin-sparing mastectomies. As with patients in the non–skin-sparing mastectomy group, patients in the skin-sparing mastectomy group who had local recurrences had an overall poorer outcome than those without local recurrence. The majority of the local recurrences (1/11) were in the subcutaneous tissue compared to the chest wall, which also reflects the character of local recurrence after non–skinsparing mastectomies as well. What is unique about this study is the evaluation of the location of the local recurrence in relation to the original tumor. The majority of the local recurrences (9/11) were within the same quadrant as the original cancer. This would likely be the case with non–skinsparing mastectomies as well, but the implication is that there could be cancer left by not resecting the overlying skin. The authors eluded to the question of
Vaughan A, Dietz JR, Aft R, et al (Washington Univ, St Louis; John Cochran Veterans Hosp, St Louis) Am J Surg 194:438-443, 2007
Background.—Local recurrence rates after skin-sparing mastectomy and immediate reconstruction are similar to recurrence rates after conventional mastectomy. We investigated the pattern of local recurrences and risk factors associated with them. Methods.—We identified 206 patients who underwent 210 skin-sparing mastectomies with immediate reconstruction from 1998 to 2006 in our database. Results.—Eleven patients had local recurrences (5.3%). Nine developed in the quadrant of the corresponding primary tumor. There were no significant dif-
162 162
®
It is reassuring to see these authors confirm previous reports of low
Breast Diseases: A Year Book Quarterly Vol 19 No 2 2008
B. A. Pockaj, MD
References 1. Menes TS, Tartter PI, Bleiweiss I, Godbold JH, Estabrook A, Smith SR. The consequence of multiple reexcisions to obtain clear lumpectomy margins in breast cancer patients. Ann Surg Oncol. 2005;12:881-885. 2. Hughes JH, Mason MC, Gray RJ, et al. A multi-site validation trial of radioactive seed localization as an alternative to wire localization. Breast J. 2008;14:153-157.
ic evaluation. Using this test in conjunction with histologic evaluation rather than in isolation will probably be more prudent for its successful integration into pathology practice. Combining the 2 tests not only will provide archivable proof of metastatic disease but also will allow a more thor-
ough sampling of the lymph node. It should be noted that well-calibrated molecular tests such as the BLN Assay could be very useful for thorough evaluation of both SLNs and non-SLNs in patients with breast cancer. S. Krishnamurthy, MD
BREAST-CONSERVING THERAPY The Effect of Multiple Reexcisions on the Risk of Local Recurrence After Breast Conserving Surgery O’Sullivan MJ, Li T, Freedman G, et al (Fox Chase Cancer Ctr, Philadelphia) Ann Surg Oncol 14:3133-3140, 2007
Background.—Guidelines for breast conserving surgery (BCS) advise mastectomy if negative margins cannot be obtained after reasonable surgical attempts. This study examined the effect of multiple reexcisions on local recurrence (LR) and identified factors predictive of the need for multiple reexcisions. Methods.—2,770 patients undergoing BCS over 25 years were analyzed; 137 patients (group A) with two or more reexcisions, 1514 patients with one reexcision (group B), and 1119 patients who had no reexcision (group C). The median follow-up was 73 months. Results.—The five and ten-year actuarial LR rates for groups A, B, and C were 5.5%, 1.9%, 2.5%, and 10%, 5.7%,
and 5.6%, respectively. The number of reexcisions did not predict for LR on multivariate analysis. Women <40 years underwent reexcision more frequently than other age groups. Patients with tumors detected by palpation alone made up 14% of the reexcision group versus 8% of the no reexcision group (p <0.001). Patients with ductal carcinoma in situ and lobular carcinoma were more likely to require reexcision than those with ductal carcinoma. On multivariate analysis, younger age, detection by physical exam only, lobular histology, smaller tumor size, and the presence of extensive intraductal component (EIC) were highly significant predictors of the need for reexcision. Conclusions.—Multiple reexcisions do not impact on LR rates if negative margins are ultimately obtained. Conversion to mastectomy based solely on the number of excisions performed is not indicated. Subsets of patients more likely to require reexcision, who may be candidates for a larger initial resection, can be identified.
One of the prerequisites for successful breast-conserving surgery is negative margins, which impact LR and overall survival. In order to achieve negative margins, re-excision of the margins in the form of a directed margin excision or the entire lumpectomy cavity may be required, although the impact of re-excision on LR has not been well analyzed. A previous report by Mennes and colleagues1 reported that multiple re-excisions were associated with an increased rate of LR. This series has only 459 patients compared with the 2,770 patients in the study by O’Sullivan and colleagues. Both had overall high re-excision rates (50% and 54%, respectively) in which 5% of the patients had 2 or more re-excisions. The overall LR rate was similar between the groups (4.7% and 6.0%, respectively). Both studies demonstrated by univariate and multivariate analyses that 1 re-excision did not impact LR. On the other hand, multivariate analysis of no re-excision versus 2 reexcisions did not significantly impact
®
Breast Diseases: A Year Book Quarterly Vol 19 No 2 2008
161 161
LR in the study by O’Sullivan and colleagues (10%), whereas the earlier study by Mennes and colleagues1 (13%) did show persistent significance. The main difference between the 2 studies was their definitions of negative margin. In the O’Sullivan study, negative margin was defined as 2 mm, and in the Mennes study, it was defined as 1 mm. Overall, these studies support the use of re-excision to achieve negative margins and suggest that patients who require more than 1 negative margin should be evaluated closely to determine their next surgical option. The other important point brought up in the current article was that they
identified patients who were at high risk for re-excision. Their findings are consistent with those of other studies. An important observation by the authors was that those who need a larger reexcision should be identified preoperatively. I think there are sufficient technologies available to surgeons to decrease re-excision rates and provide better overall outcome for patients. This includes extensive preoperative evaluation, including selected use of breast magnetic resonance imaging, intraoperative localization by radioactive seed or ultrasonography, and use of intraoperative frozen-section or touch prep cytology for margins. These procedures have
been adopted by our institution, resulting in a re-excision rate of only 8%.
Patterns of local breast cancer recurrence after skin-sparing mastectomy and immediate breast reconstruction
ferences between patients who recurred and those who did not with respect to tumor size/stage, margin status, estrogen receptor/progesterone receptor/Her2neu status, lymph node metastases, or radiation therapy (P > .05). Patients with grade 3 invasive tumors or high-grade ductal carcinoma in situ were more likely to recur than patients with grade 1 or 2 invasive tumors or low- or intermediate-grade ductal carcinoma in situ (P = .0035). Those patients who recurred had a significantly decreased overall survival compared to patients who did not recur (P = .0006). Conclusions.—Skin-sparing mastectomy and immediate reconstruction has a low local recurrence rate. Recurrences occur most commonly in the same quadrant as the primary tumor and treatment approaches include surgery, chemotherapy, and radiation therapy. Local recurrence portends a poorer overall survival.
local recurrence rates in patients undergoing skin-sparing mastectomies comparable to those undergoing nonskin-sparing mastectomies. As with patients in the non–skin-sparing mastectomy group, patients in the skin-sparing mastectomy group who had local recurrences had an overall poorer outcome than those without local recurrence. The majority of the local recurrences (1/11) were in the subcutaneous tissue compared to the chest wall, which also reflects the character of local recurrence after non–skinsparing mastectomies as well. What is unique about this study is the evaluation of the location of the local recurrence in relation to the original tumor. The majority of the local recurrences (9/11) were within the same quadrant as the original cancer. This would likely be the case with non–skinsparing mastectomies as well, but the implication is that there could be cancer left by not resecting the overlying skin. The authors eluded to the question of
Vaughan A, Dietz JR, Aft R, et al (Washington Univ, St Louis; John Cochran Veterans Hosp, St Louis) Am J Surg 194:438-443, 2007
Background.—Local recurrence rates after skin-sparing mastectomy and immediate reconstruction are similar to recurrence rates after conventional mastectomy. We investigated the pattern of local recurrences and risk factors associated with them. Methods.—We identified 206 patients who underwent 210 skin-sparing mastectomies with immediate reconstruction from 1998 to 2006 in our database. Results.—Eleven patients had local recurrences (5.3%). Nine developed in the quadrant of the corresponding primary tumor. There were no significant dif-
162 162
®
It is reassuring to see these authors confirm previous reports of low
Breast Diseases: A Year Book Quarterly Vol 19 No 2 2008
B. A. Pockaj, MD
References 1. Menes TS, Tartter PI, Bleiweiss I, Godbold JH, Estabrook A, Smith SR. The consequence of multiple reexcisions to obtain clear lumpectomy margins in breast cancer patients. Ann Surg Oncol. 2005;12:881-885. 2. Hughes JH, Mason MC, Gray RJ, et al. A multi-site validation trial of radioactive seed localization as an alternative to wire localization. Breast J. 2008;14:153-157.