Re-excision Rates and Local Recurrence in Breast Cancer Patients Undergoing Breast Conserving Therapy

Zusammenfassung

Hintergrund: Der Einfluss von Reexzisionen (RE) auf die Lokalrezidivate (LR) bei Brustkrebspatientinnen wird nach wie vor kontrovers diskutiert.

Patienten und Methoden: Diese Studie untersucht Einflussfaktoren auf die RE-Rate bei Brustkrebspatientinnen nach brusterhaltender oder onkoplastischer Operation. Zwischen 2000 und 2003 wurden 489 Patientinnen mit pT1-pT2- und pN0/1-Tumoren ausgewertet. 74 Patientinnen erfüllten die Einschlusskriterien und wurden in 3 Gruppen unterteilt: keine RE (n = 25), RE während der Primäroperation und RE in einer sekundären Operation (n = 21). Alle Tumorblöcke wurden durch einen auf Brustkrebs spezialisierten Pathologen reevaluiert.

Ergebnisse: Der durchschnittliche Beobachtungszeitraum, mit einer LR-Rate von 4,1 %, betrug 70 Monate. Binäre logistische Regressionsanalyse ergab keine tumorspezifischen Risikofaktoren für eine RE. Kein Rezidiv trat in der Gruppe ohne RE auf. In der Gruppe mit RE während der Primäroperation trat ein LR, und in der Gruppe mit RE in einer sekundären oder weiteren Operation traten 2 LR auf.

Zusammenfassung: Neue Risikofaktoren für eine erhöhte RE-Rate konnten nicht gefunden werden und spiegeln die inkonsistente Datenlage wider. Brustkrebs sollte des ungeachtet in einer Operation entfernt werden, wobei onkoplastische Techniken berücksichtigt werden müssen.

Abstract

Background: Controversy continues over the impact of re-excision (RE) on local recurrence (LR) in patients with invasive breast cancer.

Patients and Methods: We investigated factors which could effect RE rates in patients undergoing breast-conserving or oncoplastic surgery. Between 2000 and 2003, 489 patients with stage pT1-pT2 or pN0/1 tumors were evaluated. 74 patients fulfilled the inclusion criteria. Patients were categorized into 3 groups: no RE (n = 25), RE during primary surgery (n = 28), and RE performed during secondary or even tertiary procedure (n = 21). All tumor slides were re-evaluated by a pathologist specializing in breast cancer.

Results: Mean follow-up was 70 months with an overall LR rate of 4.1 %. Binary logistic regression revealed no tumor-specific risk factors for RE. There was no LR in the group of patients who did not have RE. There was one case of LR in the group of patients who had RE during primary surgery. Two cases of LR were observed in the group of patients who had two or more surgical procedures.

Conclusion: New risk factors for increased RE rates were not observed, reflecting the inconsistent data on risk factors for RE. However, breast cancers should be excised in a single procedure and oncoplastic procedures should be considered.

Key words

oncoplastic surgery - local recurrence - breast-conserving therapy - margin status - re-excision - breast cancer

Schlüsselwörter

onkoplastische Operation - Lokalrezidiv - brusterhaltende Operation - Tumorrand - Reexzision - Brustkrebs

• References

• 1 Caughran JL, Vicini FA, Kestin LL et al. Optimal use of re-excision in patients diagnosed with early-stage breast cancer by excisional biopsy treated with breast-conserving therapy. Ann Surg Oncol 2009; 16: 3020-3027
• 2 Tartter PI, Kaplan J, Bleiweiss I et al. Lumpectomy margins, reexcision, and local recurrence of breast cancer. Am J Surg 2000; 179: 81-85
• 3 Aziz D, Rawlinson 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: 331-337
• 4 Yiu CC, Loo WT, Lam CK et al. Presence of extensive intraductal component in patients undergoing breast conservative surgery predicts presence of residual disease in subsequent completion mastectomy. Chin Med J (Engl) 2009; 122: 900-905
• 5 Holland R, Connolly JL, Gelman R et al. The presence of an extensive intraductal component following a limited excision correlates with prominent residual disease in the remainder of the breast. J Clin Oncol 1990; 8: 113-118
• 6 Sanchez C, Brem RF, McSwain AP et al. Factors associated with re-excision in patients with early-stage breast cancer treated with breast conservation therapy. Am Surg 2010; 76: 331-334
• 7 Mirza NQ, Vlastos G, Meric F et al. Predictors of locoregional recurrence among patients with early-stage breast cancer treated with breast-conserving therapy. Ann Surg Oncol 2002; 9: 256-265
• 8 Smitt MC, Nowels KW, Zdeblick MJ et al. The importance of the lumpectomy surgical margin status in long-term results of breast conservation. Cancer 1995; 76: 259-267
• 9 AGO: AGO Breast Commission. Diagnosis and treatment of patients with primary and metastatic breast cancer. Recommendations. 2009 http://www.ago-online.de
• 10 Morrow M, Strom EA, Bassett LW et al. Standard for breast conservation therapy in the management of invasive breast carcinoma. CA Cancer J Clin 2002; 52: 277-300
• 11 Menes TS, Tartter PI, Bleiweiss I et al. The consequence of multiple re-excisions to obtain clear lumpectomy margins in breast cancer patients. Ann Surg Oncol 2005; 12: 881-885
• 12 OʼSullivan MJ, Li T, Freedman G et al. The effect of multiple reexcisions on the risk of local recurrence after breast conserving surgery. Ann Surg Oncol 2007; 14: 3133-3140
• 13 Meric F, Mirza NQ, Vlastos G et al. Positive surgical margins and ipsilateral breast tumor recurrence predict disease-specific survival after breast-conserving therapy. Cancer 2003; 97: 926-933
• 14 Clough KB, Kaufman GJ, Nos C et al. Improving breast cancer surgery: a classification and quadrant per quadrant atlas for oncoplastic surgery. Ann Surg Oncol 2010; 17: 1375-1391
• 15 Singletary SE, Allred C, Ashley P et al. Revision of the American Joint Committee on Cancer staging system for breast cancer. J Clin Oncol 2002; 20: 3628-3636
• 16 Miller AR, Brandao G, Prihoda TJ et al. Positive margins following surgical resection of breast carcinoma: analysis of pathologic correlates. J Surg Oncol 2004; 86: 134-140
• 17 Wazer DE, Schmidt-Ullrich RK, Ruthazer R et al. The influence of age and extensive intraductal component histology upon breast lumpectomy margin assessment as a predictor of residual tumor. Int J Radiat Oncol Biol Phys 1999; 45: 885-891
• 18 Kurniawan ED, Wong MH, Windle I et al. Predictors of surgical margin status in breast-conserving surgery within a breast screening program. Ann Surg Oncol 2008; 15: 2542-2549
• 19 Smitt MC, Horst K. Association of clinical and pathologic variables with lumpectomy surgical margin status after preoperative diagnosis or excisional biopsy of invasive breast cancer. Ann Surg Oncol 2007; 14: 1040-1044
• 20 Cabioglu N, Hunt KK, Sahin AA et al. Role for intraoperative margin assessment in patients undergoing breast-conserving surgery. Ann Surg Oncol 2007; 14: 1458-1471
• 21 Dillon MF, Hill AD, Quinn CM et al. A pathologic assessment of adequate margin status in breast-conserving therapy. Ann Surg Oncol 2006; 13: 333-339
• 22 Chagpar AB, Martin 2nd RC, Hagendoorn LJ et al. Lumpectomy margins are affected by tumor size and histologic subtype but not by biopsy technique. Am J Surg 2004; 188: 399-402
• 23 Bani MR, Lux MP, Heusinger K et al. Factors correlating with reexcision after breast-conserving therapy. Eur J Surg Oncol 2009; 35: 32-37
• 24 Sakr RA, Poulet B, Kaufman GJ et al. Clear margins for invasive lobular carcinoma: A surgical challenge. Eur J Surg Oncol 2011; 37: 350-356
• 25 Pleijhuis RG, Graafland M, de Vries J et al. Obtaining adequate surgical margins in breast-conserving therapy for patients with early-stage breast cancer: current modalities and future directions. Ann Surg Oncol 2009; 16: 2717-2730
• 26 McCahill LE, Single RM, Aiello Bowles EJ et al. Variability in reexcision following breast conservation surgery. JAMA 2012; 307: 467-475
• 27 Meier-Meitinger M, Rauh C, Adamietz B et al. Accuracy of radiological tumour size assessment and the risk for re-excision in a cohort of primary breast cancer patients. Eur J Surg Oncol 2012; 38: 44-51
• 28 Rauh C, Hack C, Häberle L et al. Percent mammographic density and dense area as risk factors for breast cancer. Geburtsh Frauenheilk 2012; 72: 727-733
• 29 Kümmel S, Kolberg HC, Lüftner D et al. Breast cancer 2011 – new aspects. Geburtsh Frauenheilk 2011; 71: 939-953
• 30 Swanson GP, Rynearson K, Symmonds R. Significance of margins of excision on breast cancer recurrence. Am J Clin Oncol 2002; 25: 438-441
• 31 Coopey S, Smith BL, Hanson S et al. The safety of multiple re-excisions after lumpectomy for breast cancer. Ann Surg Oncol 2011; 18: 3797-3801
• 32 Allweis TM, Kaufman Z, Lelcuk S et al. A prospective, randomized, controlled, multicenter study of a real-time, intraoperative probe for positive margin detection in breast-conserving surgery. Am J Surg 2008; 196: 483-489
• 33 Thill M, Roder K, Diedrich K et al. Intraoperative assessment of surgical margins during breast conserving surgery of ductal carcinoma in situ by use of radiofrequency spectroscopy. Breast 2011; 20: 579-580
• 34 Pappo I, Spector R, Schindel A et al. Diagnostic performance of a novel device for real-time margin assessment in lumpectomy specimens. J Surg Res 2009; 160: 277-281
• 35 Schulz-Wendtland R, Dilbat G, Bani MR et al. Use of tomosynthesis in intraoperative digital specimen radiography – is a reduction of breast re-excision rates possible?. Geburtsh Frauenheilk 2011; 71: 1080-1084
• 36 Böhm J, Zikán M. Einfluss der prognostischen Faktoren auf die Therapie des duktalen Carcinoma in situ der Brust. Geburtsh Frauenheilk 2011; 71: 967-972
• 37 Fasching PA, Ekici AB, Adamietz BR et al. Breast cancer risk – genes, environment and clinics. Geburtsh Frauenheilk 2011; 71: 1056-1066
• 38 Hartkopf AD, Banys M, Krawczyk N et al. Circulating tumor cells in early-stage breast cancer. Geburtsh Frauenheilk 2011; 71: 1067-1072