Breast Conservation and Negative Margins in Invasive Lobular Carcinoma: The Impact of Oncoplastic Surgery and Shave Margins in 358 Patients

Mukhtar, Rita A.; Wong, Jasmine; Piper, Merisa; Zhu, Zelos; Fahrner-Scott, Kelly; Mamounas, Matina Elise; Sbitany, Hani; Alvarado, Michael; Foster, Robert D.; Ewing, Cheryl A.; Esserman, Laura J.

doi:10.1245/s10434-018-6682-4

Cited by 30 publications

(12 citation statements)

References 27 publications

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“…The clinical and radiologic features of this type of lesion can explain this result. We know this from the literature, confirmed also by our case studies 18,19…”

Section: Discussionsupporting

confidence: 84%

<p>Positive margins (R1) risk factors in breast cancer conservative surgery</p>

Lombardi¹,

Pastore²,

Maggi³

et al. 2019

BCTT

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Background The primary goal in conservative breast cancer surgery is the complete excision of the tumor, but at the same time attempting to obtain a satisfactory postoperative esthetic result. The notion of “No Ink on Tumor” that indicates exclusively the presence of tumor cells on the inked surface of the surgical specimen is now the gold standard; however, the problem of the free margin is still a fundamental topic of debate that has not yet found a definitive solution. Methods Our retrospective analysis takes into account 1440 patients undergoing breast conservative surgery, from October 2004 to November 2018, all treated at the breast unit of our institution. Results Positive margins (R1) rate was 10.2% (147 cases out of 1440). Overall survival was 95% at 5 years and 89% at 10 years. No differences in mortality and local recurrence rate between R0 and R1 patients were found. Half of the R1 patients underwent secondary surgery with enlargement of margins, while in the other half we performed direct mastectomy. Among the analyzed variables, age, histological size, histological type, grading, multifocality, lympho-vascular invasion and lymph node status were significantly correlated with the R1 status. The multivariate analysis shows the association of age and surgical technique (oncoplastic) with R1 status. Conclusion Further studies will allow the creation of a statistical model, for better pre-operative prediction of patients with higher risk of R1 and better selection of patients to be candidates for conservative surgery.

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“…The clinical and radiologic features of this type of lesion can explain this result. We know this from the literature, confirmed also by our case studies 18,19…”

Section: Discussionsupporting

confidence: 84%

<p>Positive margins (R1) risk factors in breast cancer conservative surgery</p>

Lombardi¹,

Pastore²,

Maggi³

et al. 2019

BCTT

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“…Although no long-term differences in recurrence rates and survival between BCS and OPS have been reported 13,19,22,[43][44][45] , current evidence regarding the impact of OPS on the re-excision rate is limited because the data are from single-centre studies with relatively few patients undergoing OPS (ranging from 31 to 1177), and in most studies the methodology was weak 11,13,44,[46][47][48] . The present results are in line with a meta-analysis 19 from 2018 that found a significantly lower risk of re-excision in patients who underwent OPS compared with those who had BCS (relative risk 0⋅66, 95 per cent c.i.…”

Section: Discussionmentioning

confidence: 99%

Rates of re-excision and conversion to mastectomy after breast-conserving surgery with or without oncoplastic surgery: a nationwide population-based study

Heeg

Jensen

Hølmich

et al. 2020

British Journal of Surgery

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Background: There is no consensus regarding the impact of oncoplastic surgery (OPS) on rates of re-excision and conversion to mastectomy following breast-conserving surgery (BCS). Here these two outcomes after BCS and OPS were compared in a nationwide population-based setting. Methods: In Denmark, all OPS is registered and categorized into volume displacement, volume reduction or volume replacement. Patients who underwent BCS or OPS between 2012 and 2018 were selected from the Danish Breast Cancer Group database. Multivariable analyses were performed to adjust for confounders, and propensity score matching to limit potential confounding by indication bias. Results: A total of 13 185 patients (72⋅5 per cent) underwent BCS and 5003 (27⋅5 per cent) OPS. Volume displacement was used in 4171 patients (83⋅4 per cent), volume reduction in 679 (13⋅6 per cent) and volume replacement in 153 (3⋅1 per cent). Re-excision rates were 15⋅6 and 14⋅1 per cent after BCS and OPS respectively. After adjusting for confounders, patients were less likely to have a re-excision following OPS than BCS (odds ratio (OR) 0⋅80, 95 per cent c.i. 0⋅72 to 0⋅88), specifically after volume displacement and reduction. The rate of conversion to mastectomy was similar after OPS and BCS (3⋅2 versus 3⋅7 per cent; P = 0⋅105), but with a lower risk in adjusted analysis (OR 0⋅69, 0⋅58 to 0⋅84), specifically after volume displacement and reduction procedures. Findings were similar after propensity score matching. Conclusion: A modest decrease in re-excision rate and less frequent conversion to mastectomy were observed after OPS compared with BCS.

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“…Concerns that re-excision lumpectomy will fail to clear the margin can result in increased mastectomies, and in several series, women with ILC who have positive or close margins are significantly more likely to undergo completion mastectomy than women with IDC. 2,12–15 While many investigators have reported on high positive margin rates in ILC, to our knowledge there are scarce data reporting the success rates of re-excision lumpectomy at clearing the initially positive margin. Understanding the likelihood of success is critical for patients to make informed decisions about whether to continue to pursue breast conservation after an initial positive margin, versus undergoing completion mastectomy.…”

Section: Introductionmentioning

confidence: 99%

Success rates of re-excision after positive margins for invasive lobular carcinoma of the breast

et al. 2019

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Rates of positive margins after surgical resection of invasive lobular carcinoma (ILC) are high (ranging from 18 to 60%), yet the efficacy of re-excision lumpReceptor subtypeectomy for clearing positive margins is unknown. Concerns about the diffuse nature of ILC may drive increased rates of completion mastectomy to treat positive margins, thus lowering breast conservation rates. We therefore determined the success rate of re-excision lumpectomy in women with ILC and positive margins after surgical resection. We identified 314 cases of stage I-III ILC treated with breast conserving surgery (BCS) at the University of California, San Francisco. Surgical procedures, pathology reports, and outcomes were analyzed using univariate and multivariate statistics and Cox-proportional hazards models. We evaluated outcomes before and after the year 2014, when new margin management consensus guidelines were published. Positive initial margins occurred in 118 (37.6%) cases. Of these, 62 (52.5%) underwent re-excision lumpectomy, which cleared the margin in 74.2%. On multivariate analysis, node negativity was significantly associated with successful re-excision (odds ratio [OR] 3.99, 95% CI 1.15–13.81, p = 0.029). After 2014, we saw fewer initial positive margins (42.7% versus 25.5%, p = 0.009), second surgeries (54.6% versus 20.2%, p < 0.001), and completion mastectomies (27.7% versus 4.5%, p < 0.001). In this large cohort of women with ILC, re-excision lumpectomy was highly successful at clearing positive margins. Additionally, positive margins and completion mastectomy rates significantly decreased over time. These findings highlight improvements in management of ILC, and suggest that completion mastectomy may not be required for those with positive margins after initial BCS.

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Breast Conservation and Negative Margins in Invasive Lobular Carcinoma: The Impact of Oncoplastic Surgery and Shave Margins in 358 Patients

Abstract: Surgeons should consider routine use of oncoplastic techniques and shave margins when performing breast-conservation surgery for women with ILC as these methods are associated with significantly lower odds of having positive margins and higher breast-conservation rates.

Cited by 30 publications

References 27 publications

<p>Positive margins (R1) risk factors in breast cancer conservative surgery</p>

<p>Positive margins (R1) risk factors in breast cancer conservative surgery</p>

Rates of re-excision and conversion to mastectomy after breast-conserving surgery with or without oncoplastic surgery: a nationwide population-based study

Success rates of re-excision after positive margins for invasive lobular carcinoma of the breast

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