Skip to main content

Advertisement

SpringerLink
Log in

Intraoperative Pathologic Margin Analysis and Re-Excision to Minimize Reoperation for Patients Undergoing Breast-Conserving Surgery

  • Breast Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Reoperation rates following breast-conserving surgery (BCS) range from 10 to 40%, with marked surgeon and institutional variation.

Objective

The aim of this study was to identify factors associated with intraoperative margin re-excision, evaluate for any differences in local recurrence based on margin re-excision and determine reoperation rates with use of intraoperative margin analysis.

Patients and Methods

We analyzed consecutive patients with ductal carcinoma in situ (DCIS) or invasive breast cancer who underwent BCS at our institution between 1 January 2005 and 31 December 2016. Routine intraoperative frozen section margin analysis was performed and positive or close margins were re-excised intraoperatively. Univariate analysis was used to compare margin status and the Kaplan–Meier method was used to compare recurrence. Multivariable logistic regression was utilized to analyze factors associated with re-excision.

Results

We identified 3201 patients who underwent BCS—688 for DCIS and 2513 for invasive carcinoma. Overall, 1513 (60.2%) patients with invasive cancer and 434 (63.1%) patients with DCIS had close or positive margins that underwent intraoperative re-excision. Margin re-excision was associated with larger tumor size in both groups. The permanent pathology positive margin rate among all patients was 1.2%, and the 30-day reoperation rate for positive margins was 1.1%. Five-year local recurrence rates were 0.6% and 1.2% for patients with DCIS and invasive cancer, respectively. There was no difference in recurrence between patients with and without intraoperative margin re-excision (p = 0.92).

Conclusion

Both DCIS and invasive carcinoma had similar rates of intraoperative margin re-excision. Although intraoperative margin re-excision was common, the reoperation rate was extremely low and there was no difference in recurrence between those with or without intraoperative re-excision.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Darby S, McGale P, Correa C, et al. Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: a meta-analysis of individual patient data for 10,801 women in 17 randomized trials. Lancet. 2011; 378(9804):1707–16.

    CAS  PubMed  Google Scholar 

  2. 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(16):1233–41.

    PubMed  Google Scholar 

  3. Bernardi S, Bertozzi S, Londero AP, Gentile G, Angione V, Petri R. Influence of surgical margins on the outcome of breast cancer patients: a retrospective analysis. World J Surg. 2014; 38(9):2279–87.

    PubMed  Google Scholar 

  4. Houssami N, Macaskill P, Marinovich ML, Morrow M. The association of surgical margins and local recurrence in women with early-stage invasive breast cancer treated with breast-conserving therapy: a meta-analysis. Ann Surg Oncol. 2014; 21(3):717–30.

    PubMed  PubMed Central  Google Scholar 

  5. O’Kelly Priddy CM, Forte VA, Lang JE. The importance of surgical margins in breast cancer. J Surg Oncol. 2016; 113(3):256–63.

    PubMed  Google Scholar 

  6. McCahill LE, Single RM, Aiello Bowles EJ, et al. Variability in reexcision following breast conservation surgery. JAMA. 2012; 307:467–75.

    PubMed  Google Scholar 

  7. Singh M, Singh G, Hogan KT, Atkins KA, Schroen AT. The effect of intraoperative specimen inking on lumpectomy re-excision rates. World J Surg Oncol. 2010; 8:4.

    PubMed  PubMed Central  Google Scholar 

  8. Margenthaler JA, Gao F, Klimberg VS. Margin index: a new method for prediction of residual disease after breast-conserving surgery. Ann Surg Oncol. 2010; 17:2696–701.

    PubMed  Google Scholar 

  9. Balch GC, Mithani SK, Simpson JF, Kelley MC. Accuracy of intraoperative gross examination of surgical margin status in women undergoing partial mastectomy for breast malignancy. Am Surg. 2005; 71(1):22–7; discussion 27–8.

  10. Landercasper J, Whitacre E, Degnim AC, Al-Hamadani M. Reasons for re-excision after lumpectomy for breast cancer: insight from the American Society of Breast Surgeons Mastery (SM) database. Ann Surg Oncol. 2014; 21(10):3185–91.

    PubMed  Google Scholar 

  11. Rivere AE, Chiasson KF, Corsetti RL, Fuhrman GM. An assessment of margins after lumpectomy in breast cancer management. Am Surg. 2016; 82(2):156–60.

    PubMed  Google Scholar 

  12. Sheikh F, Pockaj B, Wasif N, Dueck A, Gray RJ. Positive Margins After breast-conserving therapy: localization technique or tumor biology. Am J Surg. 2011; 202(3):281–5.

    PubMed  Google Scholar 

  13. Jorns JM, Visscher D, Sabel M, et al. Intraoperative frozen section analysis of margins in breast conserving surgery significantly decreases re-operative rates: one-year experience at an Ambulatory Surgical Center. Am J Clin Pathol. 2012; 138(5):657–69.

    PubMed  PubMed Central  Google Scholar 

  14. Cabioglu N, Hunt KK, Sahin AA, et al. Role for intraoperative margin assessment in patients undergoing breast-conserving surgery. Ann Surg Oncol. 2007; 14(4):1458–71.

    PubMed  Google Scholar 

  15. Camp ER, McAulifee PG, 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(6):855–61.

    PubMed  Google Scholar 

  16. Chagpar A, Yen T, Sahin AA, et al. Intraoperative margin assessment reduces reexcision rates in patients with ductal carcinoma in situ treated with breast-conserving surgery. Am J Surg. 2003; 186(4):371–7.

    PubMed  Google Scholar 

  17. Fukamachi K, Ishida T, Usami S, et al. Total-circumference intraoperative frozen section analysis reduces margin-positive rate in breast-conservation surgery. Jpn J Clin Oncol. 2010; 40(6):513–20.

    PubMed  Google Scholar 

  18. Boughey JC, Hieken TJ, Jakub JW, et al. Impact of analysis of frozen-section margin on reoperation rates in women undergoing lumpectomy for breast cancer: evaluation of the national surgical quality improvement program data. Surgery. 2014; 156(1):190–7.

    PubMed  Google Scholar 

  19. Osborn JB, Keeney GL, Jakub JW, Degnim AC, Boughey JC. Cost-effectiveness analysis of routine frozen-section analysis of breast margins compared with reoperation for positive margins. Ann Surg Oncol. 2011; 18(11):3204–9.

    PubMed  Google Scholar 

  20. Wilson LB. A method for the rapid preparation of fresh tissues for the microscope. JAMA. 1905; 45:1737.

    Google Scholar 

  21. Ferreiro JA, Myers JL, Bostwick DG. Accuracy of frozen section diagnosis in surgical pathology: review of a 1-year experience with 24,880 cases at Mayo Clinic Rochester. Mayo Clin Proc. 1995; 70(12):1137–41.

    CAS  PubMed  Google Scholar 

  22. Moran MS, Schnitt SJ, Giuliano AE, et al. Society of Surgical Oncology–American Society for Radiation Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in stages I and II invasive breast cancer. Ann Surg Oncol. 2014; 21(3):704–16.

    PubMed  Google Scholar 

  23. Morrow M, Van Zee KJ, Solin LJ, et al. Society of Surgical Oncology–American Society for Radiation Oncology–American Society of Clinical Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in ductal carcinoma in situ. Ann Surg Oncol. 2016; 23(12):3801–10.

    PubMed  PubMed Central  Google Scholar 

  24. Agostinho JL, Zhao X, Sun W, et al. Prediction of positive margins following breast conserving surgery. Breast. 2015; 24(1):46–50.

    PubMed  Google Scholar 

  25. Barentsz MW, Potsma EL, van Dalen T, et al. Prediction of positive resection margins in patients with non-palpable breast cancer. Eur J Surg Oncol. 2015; 41(1):106–12.

    CAS  PubMed  Google Scholar 

  26. Jia H, Jia W, Yang Y, et al. HER-2 positive breast cancer is associated with an increased risk of positive cavity margins after initial lumpectomy. World J Surg Oncol. 2014; 12:289.

    PubMed  PubMed Central  Google Scholar 

  27. 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(2):153–7.

    PubMed  Google Scholar 

  28. Jeevan R, Cromwell DA, Trivella M, et al. Reoperation rates after breast conserving surgery for breast cancer among women in england: retrospective study of hospital episode statistics. BMJ. 2012; 345:e4505.

    CAS  PubMed  PubMed Central  Google Scholar 

  29. Talsma AK, Reedjik AM, Damhuis RA, Westenend PJ, Vles WJ. Re-resection rates after breast-conserving surgery as a performance indicator: introduction of a case-mix model to allow comparison between Dutch Hospitals. Eur J Surg Oncol. 2011; 37(4):357–63.

    CAS  PubMed  Google Scholar 

  30. Murphy BL, Boughey JC, Keeney MG, et al. Factors associated with positive margins in women undergoing breast conservation surgery. Mayo Clin Proc. 2018; 93(4):429–35.

    PubMed  Google Scholar 

  31. Jorns JM, Daignault S, Sabel MS, Myers JL, Wu AJ. Frozen sections in patients undergoing breast conserving surgery at a single ambulatory surgical center: 5 year experience. Eur J Surg Oncol. 2017; 43(7):1273–81.

    CAS  PubMed  Google Scholar 

  32. Vos EL, Gaal J, Verhoef C, Brouwer K, van Deurzen CHM, Koppert LB. Focally positive margins in breast conserving surgery: predictors, residual disease, and local recurrence. Eur J Surg Oncol. 2017; 43(10):1846–54.

    CAS  PubMed  Google Scholar 

  33. Aziz D, Rawlison E, Narod SA, et al. The role of reexcision for positive margins in optimizing local disease control after breast-conserving surgery for cancer. Breast J. 2006; 12(4):331–7.

    PubMed  Google Scholar 

  34. O’Sullivan MJ, Li T, Freedman G, Morrow M. The effect of multiple reexcisions on the risk of local recurrence after breast conserving surgery. Ann Surg Oncol. 2007; 14(11):3133–40.

    PubMed  Google Scholar 

  35. Kouzminova NB, Aggarwal S, Aggarwal A, Allo MD, Lin AY. Impact of initial surgical margins and residual cancer upon re-excision on outcome of patients with localized breast cancer. Am J Surg. 2009; 198(6):771–80.

    PubMed  Google Scholar 

  36. Ali AN, Vapiwala N, Guo M, Hwang WT, Harris EE, Solin LJ. The impact of re-excision and residual disease on local recurrence after breast conservation treatment for patients with early stage breast cancer. Clin Breast Cancer. 2011; 11(6):400–5.

    PubMed  Google Scholar 

  37. Gray RJ, Salud C, Nguyen K, et al. Randomized prospective evaluation of a novel technique for biopsy or lumpectomy of nonpalpable breast lesions: radioactive seed versus wire localization. Ann Surg Oncol. 2001; 8(9):711–5.

    CAS  PubMed  Google Scholar 

  38. Jakub JW, Gray RJ, Degnim AC, Boughey JC, Gardner M, Cox CE. Current status of radioactive seed for localization of non-palpable breast lesions. Am J Surg. 2010; 199(4):522–8.

    PubMed  Google Scholar 

  39. Murphy JO, Moo TA, Kina TA, et al. Radioactive seed localization compared to wire localization in breast-conserving surgery: initial 6-month experience. Ann Surg Oncol. 2013; 20(13):4121–7.

    PubMed  PubMed Central  Google Scholar 

  40. Sharek D, Zuley ML, Zhang JY, Soran A, Ahrendt GM, Ganott MA. Radioactive seed localization versus wire localization for lumpectomies: a comparison of outcomes. AJR Am J Roentgenol. 2015; 204(4):872–7.

    PubMed  Google Scholar 

  41. Langhans L, Tvedskov TF, Klausen TL, et al. Radioactive seed localization or wire-guided localization of nonpalpable invasive and in situ breast cancer: a randomized multicenter, open-label trial. Ann Surg. 2017; 266(1):29–35.

    PubMed  Google Scholar 

  42. Bloomquist EV, Ajkay N, Patil S, Collett AE, Frazier TG, Barrio AV. A randomized prospective comparison of patient-assessed satisfaction and clinical outcomes with radioactive seed localization versus wire localization. Breast J. 2016; 22(2):151–7.

    PubMed  Google Scholar 

  43. Lovrics PJ, Goldsmith CH, Hodgson N, et al. A multicentered, randomized, controlled trial comparing radioguided seed localization to standard wire localization for nonpalpable, invasive and in situ breast carcinomas. Ann Surg Oncol. 2011; 18(12):3407–14.

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Surgery, Mayo Clinic, Rochester, MN, USA

    Jennifer M. Racz MD, Amy C. Degnim MD, Tina J. Hieken MD, James W. Jakub MD & Judy C. Boughey MD

  2. Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Program, Mayo Clinic, Rochester, MN, USA

    Amy E. Glasgow MHA & Elizabeth B. Habermann PhD

  3. Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA

    Gary L. Keeney MD & John C. Cheville MD

Authors
  1. Jennifer M. Racz MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Amy E. Glasgow MHA
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Gary L. Keeney MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Amy C. Degnim MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Tina J. Hieken MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. James W. Jakub MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. John C. Cheville MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Elizabeth B. Habermann PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Judy C. Boughey MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Judy C. Boughey MD.

Ethics declarations

Disclosures

Jennifer M. Racz, Amy E. Glasgow, Gary L. Keeney, Amy C. Degnim, Tina J. Hieken, James W. Jakub, John C. Cheville, Elizabeth B. Habermann, and Judy C. Boughey have no disclosures to declare.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Racz, J.M., Glasgow, A.E., Keeney, G.L. et al. Intraoperative Pathologic Margin Analysis and Re-Excision to Minimize Reoperation for Patients Undergoing Breast-Conserving Surgery. Ann Surg Oncol 27, 5303–5311 (2020). https://doi.org/10.1245/s10434-020-08785-z

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1245/s10434-020-08785-z

Search

Navigation