Factors associated with residual disease after initial breast-conserving surgery for ductal carcinoma in situ (original) (raw)
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Predictive factors for positive surgical margins in the treatment of breast ductal carcinoma in situ
Context: Surgery is the main form of treatment for ductal carcinoma in situ (DCIS) of the breast. Among other factors, treatment success requires that the surgical margins are free of disease, to reduce the risk of recurrence. Aims: The purpose of this study was to analyze factors that might be associated with positive margins in patients diagnosed with DCIS. Settings and Design: A retrospective analysis was performed of hospital databases from the year 2006 to 2014, to identify patients with an initial diagnosis of DCIS made by percutaneous biopsy. Subjects and Methods: Age, the presence of disease symptoms, lesion size on mammogram, and the presence of estrogen receptors, and their relationship to the surgical margins were evaluated in 249 patients. Statistical Analysis Used: Shapiro and Wilcoxon–Mann–Whitney tests were used to verify that the data were normally distributed. Chi-squared test was used to verify the independence of the variables. Results: Lesions measuring 1.55 cm or greater had a relative risk of positive margins after conservative surgery of 1.39 (95% confidence interval [95% CI]: 1.02–1.90). The presence of symptoms had a relative risk of positive margins after conservative surgery of 1.54 (95% CI: 1.17–2.02). Conclusion: Lesions measuring 1.55 cm or greater and the presence of symptoms are risk factors for positive margins in the treatment of ductal carcinoma in situ. Therefore, these patients need a better surgical planning in order to reduce the risk of positive margins. There is a clear need for large prospective studies to validate our findings and define other factors that might contribute to the success of surgical resection for ductal carcinoma in situ. KEY WORDS: Breast surgery, ductal carcinoma in situ, surgical margins
Ductal Carcinoma In Situ and Margins <2 mm: Contemporary Outcomes With Breast Conservation
Annals of surgery, 2017
To determine the relationship between negative margin width and locoregional recurrence (LRR) in a contemporary cohort of ductal carcinoma in situ (DCIS) patients. Recent national consensus guidelines recommend an optimal margin width of 2 mm or greater for the management of DCIS; however, controversy regarding re-excision remains when managing negative margins <2 mm. One thousand four hundred ninety-one patients with DCIS who underwent breast-conserving surgery from 1996 to 2010 were identified from a prospectively managed cancer center database and analyzed using univariate and multivariate Cox proportional hazard models to determine the relationship between negative margin width and LRR with or without adjuvant radiation therapy (RT). A univariate analysis revealed that age <40 years (n = 89; P = 0.02), no RT (n = 298; P = 0.01), and negative margin width <2 mm (n = 120; P = 0.005) were associated with LRR. The association between margin width and LRR differed by adjuvan...
Annals of surgical oncology, 2016
This retrospective study was aimed at identifying clinicopathologic characteristics associated with an increased risk for ipsilateral local recurrence (LR) in patients with ductal carcinoma in situ (DCIS) treated with wide local excision (WLE) alone without radiotherapy (RT). All patients with DCIS treated with WLE alone at the Beth Israel Deaconess Medical Center, Boston, MA, USA, between the years 2000 and 2010 were identified. We collected data on demographics, parity, personal or family history of breast cancer, exogenous hormone use, tobacco use, comorbidities, genetic mutation carrier status, imaging interval, and tumor-specific characteristics. Overall, 222 patients were included in the study. Median follow-up time was 8 years. LR occurred in 9% of patients, with a recurrence rate of 11.3 per 1000 person-years. The risk of recurrence was lower for patients with nuclear grade (NG) I tumors than for patients with NG II or NG III tumors (3, 8.5, and 19%, respectively; p = 0.01)....
Journal of Surgical Oncology, 2007
Background and Objectives: To assess the effect of time on finding residual breast cancer in re-excision specimens after non-radical breast-conserving surgery for both DCIS and invasive breast carcinoma. Methods: 315 breast-conserving surgical procedures with tumour-positive margins were retrospectively reviewed. The significance of association between the presence of finding residual tumour in the re-excision specimen and mean time interval was calculated with Student's t-test. A multivariate logistic regression model was used to assess the independent relative risk of time on presence of residual tumour. Results: Residual tumour was found in 240 (76.2%) of the re-excision specimens. For primary invasive carcinomas time was a risk-reducing factor for finding residual disease (OR 0.89, 95% CI 0.82-0.98, P ¼ 0.01). If invasive carcinoma was transected, the absence of residual disease was significantly related with a longer mean time interval (OR 0.98, 95% CI 0.95-0.99, P ¼ 0.04). Conclusions: An increased time interval between primary surgery and re-excision for tumour-positive surgical margins for invasive carcinoma is associated with a decreased incidence of finding residual tumour. This could be explained by inflammatory responses after surgical trauma. For DCIS there was no influence of time on finding residual tumour, which could be explained by a more protective microenvironment of DCIS or re-growth of surviving malignant cells.
International Journal of Radiation Oncology*Biology*Physics, 2002
Purpose: Although breast-conserving surgery followed by radiotherapy (RT) has become a standard treatment option for patients with ductal carcinoma in situ of the breast, risk factors for ipsilateral breast tumor recurrence (IBTR) in these patients remain an active area of investigation. The purpose of this study was to evaluate the impact of clinical and pathologic features on long-term outcome in a cohort of DCIS patients treated with breast-conserving surgery plus RT. Methods and Materials: Between 1973 and 1998, 230 patients with DCIS were treated with breast-conserving surgery plus RT at our institution. All patients were treated by local excision followed by RT to the breast to a total median tumor bed dose of 64 Gy. Adjuvant hormonal therapy was used in only 20 patients (9%). All available clinical, pathologic, and outcome data, including ipsilateral and contralateral events, were entered into a computerized database. The clinical and pathologic variables evaluated included detection method, mammographic appearance, age, family history, histologic subtype, presence of necrosis, nuclear grade, final margin status, and use of adjuvant hormonal therapy. Results: As of December 15, 2000, with a median follow-up of 8.2 years, 17 patients had developed a recurrence in the ipsilateral breast, resulting in a 5-and 10-year IBTR rate of 5% and 13%, respectively. Contralateral breast cancer developed in 8 patients, resulting in a 10-year contralateral recurrence rate of 5%. Patient age, family history, histologic subtype, margin status, and tumor grade were not significantly associated with recurrence on univariate analysis. A significantly higher rate of local relapse was observed in patients with the presence of necrosis. The 10-year relapse rate was 22% in 88 patients with necrosis compared with 7% in 142 patients without necrosis (p <0.01). In multivariate analysis, the presence of necrosis remained a significant predictor of local relapse. No breast relapses occurred among the 8 patients with positive margins, and three relapses developed among 21 patients with close margins. The rate of IBTR in those with close/positive margins did not differ from the rate in those with negative or unknown margins. It is also notable that none of the 20 patients treated with adjuvant tamoxifen had developed IBTR or a contralateral event to date, although the follow-up on this group was still too short to reach significance. Conclusion: In this cohort of uniformly treated patients with a relatively long follow-up, the presence of necrosis was a significant predictor of local relapse. However, positive or close margin status was not a significant predictor of local relapse. Although none of the patients receiving tamoxifen had a recurrence in the ipsilateral or contralateral breast, longer follow-up is required to assess the effect of tamoxifen on these end points. © 2002 Elsevier Science Inc.
Breast conservation in ductal carcinoma in situ (DCIS): what defines optimal margins?
Histopathology, 2016
The introduction of mammographic screening has resulted in a rise in the detection rate of ductal carcinoma in situ (DCIS), currently accounting for one-fifth of screen-detected breast cancers. Although 60-70% of DCIS are treated with breast-conserving surgery (BCS) with or without radiotherapy, the frequency of subsequent surgery to re-excise positive margins in order to reduce the probability of recurrences remains high. DCIS recurrence is associated not only with financial, health and psychological implications; approximately half these recurrences are invasive disease. An appropriate margin width for patients undergoing BCS for invasive breast cancer has been largely agreed. Although there is a perception that such recommendations may be applicable to DCIS, major differences exist which may affect this application. Importantly, DCIS patients often do not receive systemic adjuvant (endocrine) therapy and not all receive radiotherapy in routine practice. There is evidence that wid...
International Journal of Radiation Oncology*Biology*Physics, 2002
Purpose: To assess the long-term outcome for women with ductal carcinoma in situ of the breast treated in current clinical practice by conservative surgery with or without definitive breast irradiation. Methods and Materials: We analyzed 705 cases of ductal carcinoma in situ treated between 1985 and 1995 in nine French regional cancer centers; 515 underwent conservative surgery and radiotherapy (CS؉RT) and 190 CS alone. The median follow-up was 7 years. Results: The 7-year crude local recurrence (LR) rate was 12.6% (95% confidence interval [CI] 9.4 -15.8) and 32.4% (95% CI 25-39.7) for the CS؉RT and CS groups, respectively (p <0.0001). The respective 10-year results were 18.2% (95% CI 13.3-23) and 43.8% (95% CI 30 -57.7). A total of 125 LRs occurred, 66 and 59 in the CS؉RT and CS groups, respectively. Invasive or microinvasive LRs occurred in 60.6% and 52% of the cases in the same respective groups. The median time to LR development was 55 and 41 months. Nine (1.7%) and 6 (3.1%) nodal recurrences occurred in the CS؉RT and CS groups, respectively. Distant metastases occurred in 1.4% and 3% of the respective groups. Patient age and excision quality (final margin status) were both significantly associated with LR risk in the CS؉RT group: the LR rate was 29%, 13%, and 8% among women aged <40, 41-60, and >61 years (p <0.001). Even in the case of complete excision, we observed a 24% rate of LR (6 of 25) in women <40 years. Patients with negative, positive, or uncertain margins had a 7-year crude LR rate of 9.7%, 25.2%, and 12.2%, respectively (p ؍ 0.008). RT reduced the LR rate in all subgroups, especially in those with comedocarcinoma (17% vs. 59% in the CS؉RT and CS groups, respectively, p <0.0001) and mixed cribriform/papillary tumors (9% vs. 31%, p <0.0001). In the multivariate Cox regression model, young age and positive margins remained significant in the CS؉RT group (p ؍ 0.00012 and p ؍ 0.016). Finally, the relative LR risk in the CS؉RT group compared with the CS group was 0.35 (95% CI 0.25-0.51, p ؍ 0.0001). Subsequent contralateral breast cancer occurred in 7.1% and 7.5% of the patients in the CS؉RT and CS groups, respectively. Conclusion: Despite the absence of randomization, our results are extremely consistent with the updated National Surgical Adjuvant Breast Project B17 and European Organization for Research and Treatment of Cancer 10853 trials. We also noted that the LR risk was very high in women <40 years and/or in the case of incomplete excision. © 2002 Elsevier Science Inc.
in Vivo, 2020
Background/Aim: Surgical margin status remains an important determinant for recurrence of invasive breast cancer and ductal carcinoma in situ. We compared the number of positive margins in initial histology with rates of residual tumor in re-excision specimens. Furthermore, we analysed cost-effectiveness of re-excisions. Patients and Methods: 101 patients treated with secondary surgery were included. The first group underwent breast conserving surgery and secondary mastectomy. The second group was primarily treated with subcutaneous mastectomy followed by secondary surgery. Results: Within the first group, 22.7% did not show residual tumor in the re-excision specimen. Of the second group, 54.3% had no residual tumor. Consequentially 45.7% needed a re-excision to achieve R0 status. Costeffectiveness was determined as secondary endpoint. If a patient needs a secondary mastectomy the hospital gains 602,65€ in comparison to a primary breast conserving operation. Conclusion: In every second patient who had first received a subcutaneous mastectomy, no tumor could be detected in the secondary operation despite a previous R1 status. Surgical margin status ("no ink on tumor") remains an important determinant for local recurrence of ductal carcinoma in situ (DCIS) and invasive breast cancer (IBC) (1, 2). Whether breast conserving surgery (BCS) or mastectomy is performed, depends on tumor size, size of the breast, patient consent and tumor biology. Positive margins after BCS or mastectomy subsequently leads to secondary surgeries (1, 3). Those are unavoidable to lower the risk of local recurrence (4-6). Of the 66,970 patients treated with surgery for DCIS or IBC in 2018, 10,070 patients underwent re-excision in Germany (7). Literature shows residual tumor rates of 33-73% within re-excision (Table I). Some studies differentiate between DCIS and IBC, but often don't distinguish between type of primary operative strategy. The primary endpoint in this study was re-excision-rates for DCIS and IBC depending on the operative strategy. We provide data regarding the significance of residual tumor within re-excisions after primary surgery with positive margins. The "diagnosis related group"-system (DRG) in Germany stipulates that even in the case of a re-operation only the costliest procedure is invoiced. The secondary endpoint in this study was the cost-effectiveness of the secondary surgery. Patients and Methods Patients treated with secondary surgery between June 2017 and March 2019 in the municipal Hospital of Cologne, Holweide, due to positive or close margins within the initial surgery were included in this study. Tumor conference protocols provided information on tumor biology, tumor size, neoadjuvant chemotherapy, primary surgery, pathology results and planned procedures. Regarding the financial implications, the "Webgrouper" of the DRG-Research-Group provides the possibility of classifying the complete hospital stay of breast cancer patients with surgery into diagnosis-related flat rates per case. This results in a total charge for the medical service within one case. The "Webgrouper" is an open source and can be used free of charge, while hospitals use certain certified software programs as groupers. The algorithms of the groupers are nevertheless the same. Within this "Webgrouper", patient related data as age, date of hospitalization and date of 2015 This article is freely accessible online.
Breast Diseases: A Year Book Quarterly, 2011
The high incidence of ductal carcinoma in situ (DCIS) and variations in its treatment have motivated studies of the comparative effectiveness of the available treatment options. In fact, the Institute of Medicine has identified the management of DCIS as a priority for comparative effectiveness research (1). DCIS itself is nonlethal. The goal of treatment is to reduce the likelihood of developing invasive breast cancer while respecting patient preferences for treatment options, which include breast-conserving surgery (BCS) alone, BCS followed by radiation, and mastectomy (2). Tamoxifen is offered to some women to reduce the risk of subsequent ipsilateral breast events, both invasive and in situ . The purpose of this study was to investigate the comparative effectiveness of the treatment strategies in the management of DCIS and key factors associated with variations in treatments and outcomes.