Keeping Abreast of Marginal Controversies

Abstract

Breast-conserving surgery, or lumpectomy, and postoperative radiation comprise the standard option for the management of most localized, early breast cancers. The procedure provides organ preservation with its attendant cosmetic and sensory benefits and has withstood the oncologic test of time. The 20-year follow-up of Bernard Fisher’s1 randomized trial demonstrated equivalent survival rates for breast conservation compared with mastectomy. In this trial, eligible lumpectomy-treated patients had the primary tumor removed with sufficient normal tissue to ensure that the inked margins were free of tumor. Although it has been demonstrated that breast cancer cells can reside in areas away from the primary tumor and that lumpectomy may not remove every last deposit,2,3 this, and other studies including a meta analysis,4 have demonstrated equivalent survival between breast conservation and breast amputation. Modern series of lumpectomy, breast radiation, and appropriate systemic management have produced long-term local control rates of 90% to 95% or greater5 and “efforts to expand eligibility. . .and to reduce the associated morbidity are well under way.”6 The goal of breast-conserving surgery is to remove all evidence of the index breast cancer in a cosmetically optimized fashion that, when combined with postoperative irradiation, a minimal rate of local recurrence is achieved. A number of tools can be used to help excise all known disease, including (1) meticulous preoperative imaging; (2) precise surgical technique with adequate margins of normal-appearing surrounding tissue; (3) use of bracketing wires for larger, nonpalpable lesions; (4) postoperative imaging to ensure that the index lesion has been totally removed; and (5) careful margin assessment of the excised specimen. Margin width or the distance from breast excised cancer cells (invasive or in situ) to the cut edge of the surgical specimen is not an end in itself. Although important, it is but one factor in the imprecise methodology used to estimate the amount of residual disease and the propensity of any residua to form a local recurrence despite other adjuvant treatments. In this month’s Annals of Surgical Oncology, Cellini et al.7 have attempted to shed light on a vexing surgical problem: Do all patients with unsatisfactory specimen margins after initial lumpectomy need re-excision? The goal of their study was to identify a subset of patients who could be spared the second surgery. They reviewed 276 patients with positive, close (study definition: 1 mm) or undetermined surgical margins after lumpectomy from a total cohort of 403 patients. They state that all initial excisions were intended as definitive procedures. The 276 patients then had either a mastectomy or reexcision. The presence or absence of residual cancer in the pathology specimen was the study’s endpoint. They found that higher grade tumors, larger tumors, and younger age increased the chance of finding residual disease. The authors did not define a subgroup that could avoid re-excision. Some aspects of this paper merit further discussion. The study’s major endpoint, the presence of residual cancer, is a pathologic finding and infers a higher rate of local recurrence. Chart review of the existing pathology reports provided the study’s data, yet no consistent, systematic methodology is described for specimen handling or pathologic evaluation of either the initial lumpectomy or the subsequent re-excision or mastectomy. Also, no attempt was made to estimate the volume of residual disease in the second surgery or location of disease within a mastectomy specimen. Furthermore, I am not convinced that all the surgeons approached their lumpectomies with the same definitive intent as the report suggests. If the study cohort of 276 Received August 5, 2004; accepted August 23, 2004. From the Department of Surgery, University of Toronto, Head, Breast Site, Princess Margaret Hospital, Toronto, Ontario, Canada. Address correspondence to: David R. McCready, MD, MSc, Department of Surgery, Princess Margaret Hospital, 610 University Ave., Suite 3-130, Toronto, Ontario, M5G 2M9 Canada; Fax: 416-946-6590; E-mail: david.mccready@uhn.on.ca

DOI: 10.1245/ASO.2004.08.910

Cite this paper

@article{McCready2004KeepingAO, title={Keeping Abreast of Marginal Controversies}, author={MSc FRCSC FACS David R. McCready}, journal={Annals of Surgical Oncology}, year={2004}, volume={11}, pages={885-887} }