Microscopic tumor cells in re-excision tissue by conservative surgery in breast cancer

Česká verzia

Authors: J. Gatěk ¹ ; P. Vážan ²; D. Vrána ³; B. Dudešek ¹; J. Duben ¹
Authors place of work: Chirurgické oddělení nemocnice Atlas Zlín, Univerzita Tomáše Bati ve Zlíně přednosta: doc. MUDr. J. Gatěk, Ph. D. ¹; CGB laboratoř Zlín přednosta: prim MUDr. D. Žiak ²; Onkologická klinika LF Univerzity Palackého, Olomouc přednosta: prof. MUDr. B. Melichar, Ph. D. ³
Published in the journal: Rozhl. Chir., 2017, roč. 96, č. 8, s. 334-339.
Category: Original articles

Summary

Introduction:
Conservative procedures in early breast carcinoma are a safe alternative to mastectomy. The resection line is controversial, as well as the presence of residual malignant cells in the breast after excision and their influence on local recurrence. The aim of the study was to assess the presence of residual cells in re-excised tissues near positive resection lines, in the distance up to 2 mm, and 2–5 mm. The distance of more than 5 mm was evaluated as free margin.

Method:
All patients operated on in Atlas Hospital from 2004 to 2008 using conservative surgery were included in study. The resection line and the presence of residual malignant cells were followed in positive margins and in the distance of the resection line from the tumour up to 2 mm, and 2–5 mm.

Results:
The conservative procedure was indicated 330 times, and 78 patients were re-operated for insufficiently free margins. The conservative procedure was completed 311 times, and mastectomy was done as the final procedure in 19 cases. Positive resection line was found 10 times. Distance up to 2 mm occurred 12 times and 2−5 mm 56 times. In all re-operated patients, presence of malignant cells in the re-excised tissue was found 31 times (39.7%). Repeated surgery for positive line, i.e. tumour present in the resection line, was done 10 times while malignant cells were found in all patients; for the distance up 2 mm, repeated surgery was done 12 times and 3 cases were positive (25%). For the distance of 2–5 mm, repeated excision occurred 56 times and 18 cases were positive, i.e. 32.1%.

Conclusion:
For the resection line “no tumour in contact with ink”, presence of malignant cells in breast tissue must be expected in one third of the cases.

Key words:
breast carcinoma – conservative surgery – residual malignant cells

Zdroje

1. Veronesi U, Salvadori B, Luini A, et al. Conservative treatment of early breast cancer. Ann Surg 1990;211:250−9.

2. Veronesi U, Banff A, Salvadori B, et al. Breast conservation is the treatment of choice in small breast cancer. Long term results of a randomized trial. Eur J Cancer 1990;26:668−70.

3. Fisher B, Redmond C, Poisson R, et al. Eight-year results of a randomized clinical trial comparing total mastectomy and lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med 1989;320:822−8.

4. Arriagada R, Le MG, Rochard F, et al. Conservative treatment versus mastectomy in early breast cancer: pattern of failure with fifteen years of follow up. J Clin Oncol 1996;14:1558−64.

5. NIH concensus conference treatment of early-stage breast cancer. JAMA 1991;265:391−5.

6. Duda M, Hartl P, Hartlová M, et al. Záchovné operace karcinomu prsu. Rozhl Chir 1997;76:605−8.

7. Gatěk J, Duben J, Dudešek B, et al. Výsledky konzervativní terapie u časného karcinomu prsu. Rozhl Chir 2000;79:201−5.

8. Gatěk J, Kotoč J, Kotočová K, et al. Lokoregionální recidivy po konzervativních výkonech u časného karcinomu prsu. Rozhl Chir 2010;89:604−11.

9. Singletary SE. Surgical margins in patients with early-stage breast cancer treated with breast conservation therapy. Am J Surg 2002;184:383−93.

10. Houssami N, Macaskill P, Marinovich L, et al. 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;21:717−30.

11. Houssami N, Macaskill P, Marinovich L, et al. Meta-analysis of the impact of surgical margins on local recurrence in women with early-stage invasive breast cancer treated with breast-conserving therapy. European J Cancer 2010;46:3219−32.

12. Kaufmann M, Morrow M, Minckwitz G. Locoregional treatment of primary breast cancer. Cancer 2010;116:184−91.

13. Ramanah R, Pivot X, Sautiere J, et al. Predictors of re-excision for positive or close margins in breast-conservation therapy for pT1 tumors. Am J Surg 2008;195:770−4.

14. Papa M, Zippel D, Koller M, et al. Positive margins of breast biopsy: Is reexcision always necessary? Surg Oncol 199;70:167−71.

15. Cellini C, Hollenbeck T, Christos P, et al. Factors associated with residual breast cancer after re-excision for close or positive margins. Ann Surg Oncol 2004;11:915−20.

16. Luu HH, Otis CN, Reed SP, et al. The unsatisfactory margin in breast cancer surgery. Am J Surg 1999;178:362−6.

17. Heves L, Imkampe A, Haji A, et al. Importance of routine cavity sampling in breast conservation surgery. B J Surg 2009;96:47−53.

18. Malik H, Purushotham A, Mallon A, et al. Influence of tumour bed assessment on local recurrence following breast conserving surgery for breast cancer. Eur J Surg Oncol 1999;25:265−8.

19. Rubin P, O´Hanlon D, Browell D, et al. Tumor bed biopsy detects the presence of multifocal disease in patients undergoing breast conservation therapy for primary breast carcinoma. Eur J Surg Oncol 1996;22:23−6.

20. Gatek J, Vrana D, Lukesova L, et al. Significance of resection margin as a risk factor for local control of early stage breast cancer. Biometrical Papers 2013;3:209−13.

21. Gatek J, Vrana D, Melichar B, et al. Significance of the resection margin and risk factors for close or positive resection margin in patients undergoing breast-conserving surgery. Journal of BUON 2012;3:452−6.

22. Holland R, Veiling S, Mravunac M, et al. Histologic multifocality of Tis, T1-2 breast carcinomas: Implications for clinical trials of breast-conserving surgery. Cancer 1985;56:979−90.

23. Chagpar A, Yen T, Sahin A. Intraoperative margin assessment reduces reexcision rates in patients with ductal carcinoma in situ treated with breast-conserving surgery. Am J Surg 2003;186:371−7.

24. DiBiase S, Komarnicky LT, Schwartz GF, et al. The number of positive margins influences the outcome of women treated with breast preservation for early stage breast carcinoma. Cancer 1998;82:2212−20.

25. Klimberg VS, Westbrook KC, Korourian S. Use of touch preps for diagnosis and evaluation of surgical margins in breast cancer. Ann Surg Oncol 1998;5:220−6.

26. Saarela AO, Paloneva TK, Rissanen TJ, et al. Determinants of positive histologic margins and residual tumor after lumpectomy for early breast cancer: a prospective study with special reference to touch preparation cytology. J Surg Oncol 1997;66:248−53.

27. Camp ER, McAuliffe PF, 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;6:855−61.

28. 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;156:190−7.

29. 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. J Clin Oncol 2014;32:1507–15.

30. Coates A, Winer E, Goldhirsch A, et al. Tailoring therapies – improving the management of early breast cancer: St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2015. Ann Surg 2015;26:1533−46.

31. Morrow M, Harris J, Schnitt J. Surgical margins in lumpectomy for breast cancer – bigger is not better. N Engl J Med 2012;367:79−83.

32. Hunt K, Smith B, Mitterndorf E. The controversy regarding margin width in breast cancer: enough is enough. Ann Surg Oncol 2014;21:701−3.