Importance of margin in BCS

1. Importance of Margin in
Breast Conserving Surgery
9th EBCC Presentation - Bodilsen et al (Aarhus
University; DBCG) – March, 2014
Sayan

2. • The status of the surgical margins is assessed by applying ink to the
surface of the lumpectomy specimen and determining the
microscopic distance between tumour cells and the inked surface.
• Still no consensus on what constitutes an optimal negative margin.

4. • 33 studies; 28162 patients; 1,506 IBTRs
• A positive margin is associated with at least a 2-fold increase in IBTR.
This increased risk in IBTR is not nullified by:
a) Delivery of a boost dose of radiation
b) Delivery of systemic therapy
c) Favourable biology
• Wider negative margins are unlikely to reduce the risks of IBTR

5. • The overall cumulative incidence of IBTR at 10 years was 10.2% without a
boost and 6.2% with a boost (P<.001).
• In the small subset of 251 patients who had positive margins and received a
boost, the cumulative incidence of IBTR at 10 years was 17.5% with 10 Gy
and 10.8% with 26 Gy (P>.10).
• Although boost reduces IBTR when margins are microscopically positive, the
absolute benefit is not sufficient to reduce the rate of IBTR to that seen with
negative margins and the use of a boost.
Jones HA et al. Impact of pathological characteristics on local relapse
after breast-conserving therapy: A subgroup analysis of the EORTC
boost versus no boost trial. J Clin Oncol 2009;27:4939-4947.

7. Patient Characteristics

8. Patient Characteristics

9. Patient Characteristics

10. Patient Characteristics

11. Patient Characteristics

12. Patient Characteristics

13. Adjuvant Therapy

14. No Difference in IBTR with BIGGER Margins!!!
0-1 mm : not reported
Mean Observation
time – 5.6 years

15. Local Recurrence

16. Adjusted Analyses

17. Adjusted Analyses

18. Adjusted Analyses

19. Adjusted Analyses

20. Adjusted Analyses

21. Adjusted Analyses

22. Adjusted Analyses

24. Conclusion
• In a national cohort of 12166 women, the 5 year cumulative risk of
IBTR: 2.4%
• No evidence of decreased risk of IBTR with margins wider than 1mm
• Predictors of IBTR include:
 Tumor on inked margin
 Young age
 ≥ 10 positive lymph nodes
 ER negativity
 No chemotherapy
 Re-excision
 DCIS outside invasive tumor

25. “The use of no ink on tumour [no cancer cells adjacent to any inked
edge/surface of the specimen] as the standard for an adequate margin
in invasive cancer in the era of multidisciplinary therapy is associated
with low rates of IBTR and has the potential to decrease re-excision
rates, improve cosmetic outcomes, and decrease healthcare costs.”

26. Summary of Clinical Practice Guideline Recommendations

27. Questions yet to be answered???
• Can these findings be extrapolated to pure DCIS which has a
discontinuous growth pattern of low‐ and intermediate‐grade DCIS
and is managed without systemic therapy?
• Are the results applicable in patients undergoing BCS following NACT
especially when the tumor does not shrink concentrically but gets
scattered into small masses?
• Are wider margins are required for patients treated with accelerated
partial breast irradiation?