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CME Topicgroups, respectively.13 However, in examining the LR rates mammography; as a result, a wide margin is recommendedin patients with negative margin, no clear cut differences for excision. Randomized controlled trials, namely NSABPbased on the exact margin width were found. Whether pa- B-17,3 UKCCCR,6 and EOTRC 108534,5 showed that BCTtients with close margin had a LR rate equivalent to those followed by radiotherapy reduced the risk of noninvasive andwith a positive margin, negative margin, or intermediate mar- invasive recurrences in the ipsilateral breast when comparedgin was unclear. with local excision alone. The incidence of invasive ipsilat- eral breast recurrence in patients who received radiotherapyMargins for DCIS was 3.9% and 5.8% at 5 yrs in NSABP B-17 trial and EORTC DCIS is a local disease lacking stromal invasion and 10853 trial, respectively, which was lower than the excisiondistant metastases. The presentation varies from a palpable group. Data from the pathological review of NSABP B-17mass to microcalcifications on mammography. The work by and EORTC 10853 trials showed that the risk of LR wasHolland showed that the histological size of DCIS might not higher in patients who did not have free margins.5,16 Unfor-correlate with mammographic findings.14,15 The reliability of tunately, the trial eligibility criteria did not require reportingmammography in assessing tumor size was related to both the of margin widths in all 3 trials. Only 5% of the pathologicalhistological type and the type of microcalcifications seen on reports did specify the exact distance in the EORTC trial.4,5Table 1. Summary of reported rates of local recurrence after breast-conserving therapy for ductal carcinoma insituaAuthor Margin (mm) N Management LR (%) Follow-up (mo) ConclusionSilverstein23 10 mm 93 Excision 2.2 Mean 81 No reduction in probability of LR with addition of postop RT if margin is 10 mm 10 mm 40 Excision RT 2.5 — —Kestin24 2b 44 Excision RT 5.9 Median 84 Margin status alone may not predict complete tumor extirpation adequately 2 88 Excision RT 15.1 — —Chan17 1 66 Excisionc 37.9 Median 47 Margins greater than 1 mm regardless of width of clearance was associated with a low LR 1.1–5 89 — 3.5 — — 5.1–10 28 — 7.1 — — 10 22 — 4.5 — —Vicini25 2 46 Excision RT 11.0 Median 87 Margin status alone may be suboptimal in accurately defining excision adequacy 2 99 Excision RT 2.0 — —Vargas21 2 34 Excision 13.0 Median 73 Margins 2 mm are shown to be an independent predictor of LR 2 198 Excision 4.0 — —MacDonald22 0 (transected) 32 Excision 46.7 Median 57 Margin width is the single most important factor in predicting LR after excision alone for DCIS 0.1–0.9 53 Excision 34.0 — — 1.0–1.9 20 Excision 35.0 — — 2.0–2.9 82 Excision 24.4 — — 3.0–5.9 39 Excision 20.5 — — 6.0–9.9 22 Excision 9.1 — — 10 197 Excision 4.6 — —MacDonald18 10 212 Excision 5.7 Median 53 Low risk of LR after excision alone for DCIS with margins 10 mm 10 60 Excision RT 1.7 — —West19 5 82 Excision RT 1.4 Median 97 5 mm margin plus radiation results in low rates of recurrence 10 71 Excision 6.0 — —a RT, radiotherapy; LR, local recurrence; DCIS, ductal carcinoma in situ.b Includes uncertain margin (n 3).c Majority of patients received excision only, other patient received adjuvant radiotherapy tamoxifen.Southern Medical Journal • Volume 102, Number 12, December 2009 1235
CME Topic 3. Fisher B, Costantino J, Redmond C, et al. Lumpectomy compared with 21. Vargas C, Kestin L, Go N, et al. Factors associated with local recurrence lumpectomy and radiation therapy for the treatment of intraductal breast and cause-specific survival in patients with ductal carcinoma in situ of cancer. N Engl J Med 1993;328:1581–1586. the breast treated with breast-conserving therapy or mastectomy. Int J 4. Julien JP, Bijker N, Fentiman IS, et al. Radiotherapy in breast-conserv- Radiat Oncol Biol Phys 2005;63:1514 –1521. ing treatment for ductal carcinoma in situ: first results of the EORTC 22. MacDonald HR, Silverstein MJ, Mabry H, et al. Local control in ductal randomised phase III trial 10853. EORTC Breast Cancer Cooperative carcinoma in situ treated by excision alone: incremental benefit of larger Group and EORTC Radiotherapy Group. Lancet 2000;355:528 –533. margins. Am J Surg 2005;190:521–525. 5. Bijker N, Peterse JL, Duchateau L, et al. Risk factors for recurrence and 23. Silverstein MJ, Lagios MD, Groshen S, et al. The influence of margin metastasis after breast-conserving therapy for ductal carcinoma-in-situ: width on local control of ductal carcinoma in situ of the breast. N Engl analysis of European Organization for Research and Treatment of Can- J Med 1999;340:1455–1461. cer Trial 10853. J Clin Oncol 2001;19:2263–2271. 24. Kestin LL, Goldstein NS, Lacerna MD, et al. Factors associated with 6. Houghton J, George WD, Cuzick J, et al; UK Coordinating Committee local recurrence of mammographically detected ductal carcinoma in situ on Cancer Research; Ductal Carcinoma in situ Working Party; DCIS in patients given breast-conserving therapy. Cancer 2000;88:596 – 607. trialists in the UK, Australia, and New Zealand. Radiotherapy and ta- 25. Vicini FA, Kestin LL, Goldstein NS, et al. Relationship between exci- moxifen in women with completely excised ductal carcinoma in situ of sion volume, margin status and tumor size with the development of local the breast in the UK, Australia, and New Zealand: Randomised con- recurrence in patients with ductal carcinoma in situ treated with breast- trolled trial. Lancet 2003;362:95–102. conserving therapy. J Surg Oncol 2001;76:245–254. 7. Veronesi U, Volterrani F, Luini A, et al. Quadrantectomy versus lumpec- 26. Silverstein MJ, Lagios MD, Craig PH, et al. A prognostic index for tomy for small size breast cancer. Eur J Cancer 1990;26:671– 673. ductal carcinoma in situ of the breast. Cancer 1996;77:2267–2274. 8. van Dongen JA, Bartelink H, Fentiman IS, et al. Factors influencing 27. Silverstein MJ. The University of Southern California/Van Nuys prog- local relapse and survival and results of salvage treatment after breast- nostic index for ductal carcinoma in situ of the breast. Am J Surg 2003; conserving therapy in operable breast cancer: EORTC trial 10801, breast 186:337–343. conservation compared with mastectomy in TNM stage I and II 28. National Comprehensive Cancer Network. Clinical Practice Guidelines breast cancer. Eur J Cancer 1992;28A:801– 805. in oncology–Breast Cancer, v2.2008 [PDF on Internet]. Available at: 9. DiBiase SJ, Komarnicky LT, Schwartz GF, et al. The number of positive www.nccn.org. Accessed April 3, 2008. margins influences the outcome of women treated with breast preserva- 29. Papa MZ, Zippel D, Koller M, et al. Positive margins of breast biopsy: tion for early stage breast carcinoma. Cancer 1998;82:2212–2220. is reexcision always necessary? J Surg Oncol 1999;70:167–171.10. Mansfield CM, Komarnicky LT, Schwartz GF, et al. Ten-year results in 30. Luini A, Rososchansky J, Gatti G, et al. The surgical margin after 1070 patients with stages I and II breast cancer treated by conservative breast-conserving surgery: discussion of an open issue. Breast Cancer surgery and radiation therapy. Cancer 1995;75:2328 –2336. Res Treat 2009;113:397– 402.11. Gage I, Schnitt SJ, Nixon AJ, et al. Pathologic margin involvement and 31. Cabioglu N, Hunt KK, Sahin AA, et al. Role of intraoperative margin the risk of recurrence in patients treated with breast conserving therapy. assessment in patients undergoing breast-conserving surgery. Ann Surg Cancer 1996;78:1921–1928. Oncol 2007;14:1458 –1471.12. Peterson ME, Schultz DJ, Reynolds C, et al. Outcomes in breast cancer 32. Olson TP, Harter J, Munoz A, et al. Frozen section analysis for intra- ˜ patients relative to margin status after treatment with breast-conserving operative margin assessment during breast-conserving surgery results in surgery and radiation therapy: the University of Pennsylvania experi- low rates of re-excision and local recurrence. Ann Surg Oncol 2007;14: ence. Int J Radiat Oncol Biol Phys 1999;43:1029 –1035. 2953–2960.13. Singletary SE. Surgical margins in patients with early-stage breast can- 33. Weinberg E, Cox C, Dupont E, et al. Local recurrence in lumpectomy cer treated with breast conservation therapy. Am J Surg 2002;184:383– patients after imprint cytology margin evaluation. Am J Surg 2004;188: 393. 349 –54.14. Holland R, Hendriks JH, Vebeek AL, et al. Extent, distribution, and 34. Bakhshandeh M, Tutuncuoglu SO, Fischer G, et al. Use of imprint mammographic/histological correlations of breast ductal carcinoma in cytology for assessment of surgical margins in lumpectomy specimens situ. Lancet 1990;335:519 –522. of breast cancer patients. Diagn Cytopathol 2007;35:656 – 659. 35. Moore MM, Whitney LA, Cerilli, et al. Intraoperative ultrasound is15. Holland R, Peterse JL, Millis RR, et al. Ductal carcinoma in situ: a associated with clear lumpectomy margins for palpable infiltrating duc- proposal for a new classification. Semin Diagn Pathol 1994;11:167–180. tal breast carcinoma. Ann Surg 2001;233:761–768.16. Fisher ER, Costantino J, Fisher B, et al. Pathologic findings from the 36. Mazouni C, Rouzier R, Balleyguier C, et al. Specimen radiography as National Surgical Adjuvant Breast Project (NSABP) protocol B-17. In- predictor of resection margin status in non-palpable breast lesions. Clin traductal carcinoma (ductal carcinoma in situ). The National Surgical Radiol 2006;61:789 –796. Adjuvant Breast and Bowel Project Collaborating Investigators. Cancer 1995;75:1310 –1319. 37. Clough KB, Lewis JS, Couturaud B, et al. Oncoplastic techniques allow extensive resection for breast-conserving therapy of breast carcinomas.17. Chan KC, Knox WF, Sinha G, et al. Extent of excision margin width Ann Surg 2003;237:26 –34. required in breast conserving surgery for ductal carcinoma in situ. Can- 38. Asgeirsson KS, Rasheed T, McCulley SJ, et al. Oncoplastic and cos- cer 2001;91:9 –16. metic outcomes of oncoplastic breast conserving therapy. Eur J Surg18. MacDonald HR, Silverstein MJ, Lee LA, et al. Margin width as the sole Oncol 2005;31:817– 823. determinant of local recurrence after breast conservation in patients with 39. Rietjens M, Urban CA, Rey PC, et al. Long-term oncological results of ductal carcinoma in situ of the breast. Am J Surg 2006;192:420 – 422. breast conservative treatment with oncoplastic surgery. Breast 2007;16:19. West JG, Qureshi A, Liao SY, et al. Multidisciplinary management of 387–395. ductal carcinoma in situ: a 10-year experience. Am J Surg 2007;194: 40. von Smitten K. Margin status after breast-conserving treatment of breast 532–534. cancer: how much free margin is enough? J Surg Oncol 2008;98:585–587.20. Neuschatz AC, DiPetrillo T, Steinhoff M, et al. The value of breast 41. Meijnen P, Gilhuijs KG, Rutgers EJ. The effects of margins on the lumpectomy margin assessment as a predictor of residual tumor burden clinical management of ductal carcinoma in situ of the breast. J Surg in ductal carcinoma in situ of the breast. Cancer 2002;94:1917–1924. Oncol 2008;98:579 –584.Southern Medical Journal • Volume 102, Number 12, December 2009 1237