Breast-conserving surgery (BCS) is the treatment of choice for early breast cancer. The adequacy of surgical margins (SM) is a crucial issue for adjusting the volume of excision and for avoiding local recurrences, although the precise definition of an adequate margins width remains controversial. Moreover, other factors such as the biological behaviour of the tumor and subsequent proper systemic therapies may influence the local recurrence rate (LRR). However, a successful BCS requires preoperative localization techniques or margin assessment techniques. Carbon marking, wire-guided, biopsy clips, radio-guided, ultrasound-guided, frozen section analysis, imprint cytology, and cavity shave margins are commonly used, but from the literature review, no single technique proved to be better among the various ones. Thus, an association of two or more methods could result in a decrease in rates of involved margins. Each institute should adopt its most congenial techniques, based on the senologic equipe experience, skills, and technologies. 1. Introduction Breast-conserving surgery (BCS) is the treatment of choice for early breast cancer [1, 2]. Various randomized trials have reported this approach to be safe and effective, thus determining a decrease in the adoption of mastectomy as the treatment of choice for early invasive breast cancer [3, 4]. BCS can almost be considered the gold standard of early stage invasive breast cancer treatment, allowing to achieve adequate surgical margins (SM) with an acceptable cosmetic outcome. Some studies have defined the adequacy of SM by its correlation with the locoregional recurrence rate (LRR) [5–14], but the precise definition of an adequate margins width remains controversial [15–17]. However, there is no doubt that obtaining negative margins decreases the risk of local recurrence [1]. Some clinical trials have demonstrated that systemic therapies may also improve the local control in breast cancer [18, 19]. Thus, there seems to be noted a recent trend of reconsideration of the importance of margin width on the incidence of local recurrences, in favour of other prognostic factors such as the biological behaviour of the tumor [15–19]. A requirement for successful BCS is a careful preoperative planning with proper localization of the lesion, especially in nonpalpable breast lesions [1]. In order to obtain adequate excisions, margins assessment techniques are also available. Wire-guided localization, radio-guided occult lesion localization (ROLL), carbon marking, intraoperative ultrasound-guided localization, cavity shave
References
[1]
S. E. Singletary, “Surgical margins in patients with early-stage breast cancer treated with breast conservation therapy,” American Journal of Surgery, vol. 184, no. 5, pp. 383–393, 2002.
[2]
E. R. Fisher, S. Anderson, C. Redmond, and B. Fisher, “Ipsilaterial breast tumor recurrence and survival following lumpectomy and irradiation: pathological findings from NSABP protocol B-06,” Seminars in Surgical Oncology, vol. 8, no. 3, pp. 161–166, 1992.
[3]
B. Fisher, S. Anderson, J. Bryant et al., “Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer,” The New England Journal of Medicine, vol. 347, no. 16, pp. 1233–1241, 2002.
[4]
U. Veronesi, N. Cascinelli, L. Mariani et al., “Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer,” The New England Journal of Medicine, vol. 347, no. 16, pp. 1227–1232, 2002.
[5]
I. Gage, S. J. Schnitt, A. J. Nixon et al., “Pathologic margin involvement and the risk of recurrence in patients treated with breast-conserving therapy,” Cancer, vol. 9, pp. 1921–1928, 1996.
[6]
S. J. Schnitt, A. Abner, R. Gelman et al., “The relationship between microscopic margins of resection and the risk of local recurrence in patients with breast cancer treated with breast-conserving surgery and radiation therapy,” Cancer, vol. 74, pp. 1746–1751, 1994.
[7]
C. C. Park, M. Mitsumori, A. Nixon et al., “Outcome at 8 years after breast-conserving surgery and radiation therapy for invasive breast cancer: influence of margin status and systemic therapy on local recurrence,” Journal of Clinical Oncology, vol. 18, no. 8, pp. 1668–1675, 2000.
[8]
M. E. Peterson, D. J. Schultz, C. Reynolds, and L. J. Solin, “Outcomes in breast cancer patients relative to margin status after treatment with breast-conserving surgery and radiation therapy: the University of Pennsylvania experience,” International Journal of Radiation Oncology Biology Physics, vol. 43, no. 5, pp. 1029–1035, 1999.
[9]
J. Horiguchi, Y. Koibuchi, H. Takei et al., “Breast-conserving surgery following radiation therapy of 50 Gy in stages I and II carcinoma of the breast: the experience at one institute in Japan,” Oncology Reports, vol. 9, no. 5, pp. 1053–1057, 2002.
[10]
K. Karasawa, T. Obara, T. Shimizu et al., “Outcome of breast-conserving therapy in the Tokyo women's medical university breast cancer society experience,” Breast Cancer, vol. 10, no. 4, pp. 341–348, 2003.
[11]
C. A. Perez, “Conservation therapy in T1-T2 breast cancer: past, current issues, and future challenges and opportunities,” Cancer Journal, vol. 9, no. 6, pp. 442–453, 2003.
[12]
R. J. Santiago, L. Wu, E. Harris et al., “Fifteen-year results of breast-conserving surgery and definitive irradiation for Stage I and II breast carcinoma: the University of Pennsylvania experience,” International Journal of Radiation Oncology Biology Physics, vol. 58, no. 1, pp. 233–240, 2004.
[13]
K. Karasawa, M. Mitsumori, C. Yamauchi et al., “Treatment outcome of breast-conserving therapy in patients with positive or close resection margins: Japanese muiti institute survey for radiation dose effect,” Breast Cancer, vol. 12, no. 2, pp. 91–98, 2005.
[14]
B. Kreike, A. A. M. Hart, T. van de Velde et al., “Continuing risk of ipsilateral breast relapse after breast-conserving therapy at long-term follow-up,” International Journal of Radiation Oncology Biology Physics, vol. 71, no. 4, pp. 1014–1021, 2008.
[15]
N. Houssami, P. Macaskill, M. L. Marinovich 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 Journal of Cancer, vol. 46, no. 18, pp. 3219–3232, 2010.
[16]
M. Morrow, J. R. Harris, and S. J. Schnitt, “Surgical margins in lumpectomy for breast cancer—bigger is not better,” The New England Journal of Medicine, vol. 367, pp. 79–82, 2012.
[17]
J. M. Dixon and N. Houssami, “Bigger margins are not better in breast conserving surgery,” British Medical Journal, vol. 345, Article ID e5855, 2012.
[18]
B. Fisher, J. Dignam, J. Bryant et al., “Five versus more than five years of tamoxifen therapy for breast cancer patients with negative lymph nodes and estrogen receptor-positive tumors,” Journal of the National Cancer Institute, vol. 88, no. 21, pp. 1529–1542, 1996.
[19]
B. Fisher, J. Dignam, E. P. Mamounas et al., “Sequential methotrexate and fluorouracil for the treatment of node-negative breast cancer patients with estrogen receptor-negative tumors: eight-year results from National Surgical Adjuvant Breast and Bowel Project (NSABP) B-13 and first report of findings from NSABP B-19 comparing methotrexate and fluorouracil with conventional cyclophosphamide, methotrexate and fluorouracil,” Journal of Clinical Oncology, vol. 14, pp. 1982–1992, 1996.
[20]
P. I. Tartter, I. J. Bleiweiss, and S. Levchenko, “Factors associated with clear biopsy margins and clear reexcision margins in breast cancer specimens from candidates for breast conservation,” Journal of the American College of Surgeons, vol. 185, no. 3, pp. 268–273, 1997.
[21]
E. D. Kurniawan, M. H. Wong, I. Windle et al., “Predictors of surgical margin status in breast-conserving surgery within a breast screening program,” Annals of Surgical Oncology, vol. 15, no. 9, pp. 2542–2549, 2008.
[22]
M. Reedijk, N. Hodgson, G. Gohla et al., “A prospective study of tumor and technical factors associated with positive margins in breast-conservation therapy for nonpalpable malignancy,” The American Journal of Surgery, vol. 204, pp. 263–268, 2012.
[23]
H. C. Shin, W. Han, H. G. Moon et al., “Nomogram for predicting positive resection margins after breast-conserving surgery,” Breast Cancer Research and Treatment, vol. 134, pp. 1115–1123, 2012.
[24]
B. Cady, M. D. Stone, J. G. Schuler, R. Thakur, M. A. Wanner, and P. T. Lavin, “The new era in breast cancer: invasion, size, and nodal involvement dramatically decreasing as a result of mammographic screening,” Archives of Surgery, vol. 131, no. 3, pp. 301–308, 1996.
[25]
M. J. Silverstein, M. D. Lagios, S. Groshen et al., “The influence of margin width on local control of ductal carcinoma in situ of the breast,” The New England Journal of Medicine, vol. 340, no. 19, pp. 1455–1461, 1999.
[26]
U. Rudloff, E. Brogi, A. S. Reiner et al., “The influence of margin width and volume of disease near margin on benefit of radiation therapy for women with DCIS treated with breast-conserving therapy,” Annals of Surgery, vol. 251, no. 4, pp. 583–591, 2010.
[27]
F. A. Vicini, L. L. Kestin, N. S. Goldstein, K. L. Baglan, J. E. Pettinga, and A. A. Martinez, “Relationship between excision volume, margin status, and tumor size with the development of local recurrence in patients with ductal carcinoma-in-situ treated with breast-conserving therapy,” Journal of Surgical Oncology, vol. 76, no. 4, pp. 245–254, 2001.
[28]
S.-Y. Wang, H. Chu, T. Shamliyan et al., “Network meta-analysis of margin threshold for women with ductal carcinoma in situ,” Journal of the National Cancer Institute, vol. 104, no. 7, pp. 507–516, 2012.
[29]
J. A. Margenthaler, “Optimizing conservative breast surgery,” Journal of Surgical Oncology, vol. 103, no. 4, pp. 306–312, 2011.
[30]
B. O. Anderson, R. Masetti, and M. J. Silverstein, “Oncoplastic approaches to partial mastectomy: an overview of volume-displacement techniques,” Lancet Oncology, vol. 6, no. 3, pp. 145–157, 2005.
[31]
S. L. Spear, C. V. Pelletiere, A. J. Wolfe, T. N. Tsangaris, and M. F. Pennanen, “Experience with reduction mammaplasty combined with breast conservation therapy in the treatment of breast cancer,” Plastic and Reconstructive Surgery, vol. 111, no. 3, pp. 1102–1109, 2003.
[32]
S. K. Down, P. K. Jha, A. Burger, and M. I. Hussien, “Oncological advantages of oncoplastic breast-conserving surgery in treatment of early breast cancer,” Breast Journal, vol. 19, pp. 56–63, 2013.
[33]
A. Losken, C. S. Dugal, T. M. Styblo, and G. W. Carlson, “A meta-analysis comparing breast conservation therapy alone to the oncoplastic technique,” Annals of Plastic Surgery, 2013.
[34]
G. Canavese, A. Catturich, C. Vecchio et al., “Pre-operative localization of non-palpable lesions in breast cancer by charcoal suspension,” European Journal of Surgical Oncology, vol. 21, no. 1, pp. 47–49, 1995.
[35]
K. Ko, B.-K. Han, M. J. Kyung et al., “The value of ultrasound-guided tattooing localization of nonpalpable breast lesions,” Korean Journal of Radiology, vol. 8, no. 4, pp. 295–301, 2007.
[36]
M. L. Ruiz-Delgado, J. A. Lòpez-Ruiz, and A. Sàiz-Lòpez, “Abnormal mammography and sonography associated with foreign-body giant-cell reaction after stereotactic vacuum-assisted breast biopsy with carbon marking,” Acta Radiologica, vol. 49, no. 10, pp. 1112–1118, 2008.
[37]
A. Rose, J. P. Collins, P. Neerhut, C. V. Bishop, and G. B. Mann, “Carbon localisation of impalpable breast lesions,” Breast, vol. 12, no. 4, pp. 264–269, 2003.
[38]
D. B. Kopans and C. A. Swann, “Preoperative imaging-guided needle placement and localization of clinically occult breast lesions,” American Journal of Roentgenology, vol. 152, no. 1, pp. 1–9, 1989.
[39]
D. B. Kopans, J. E. Meyer, K. K. Lindfors, and S. S. Bucchianeri, “Breast sonography to guide cyst aspiration and wire localization of occult solid lesions,” American Journal of Roentgenology, vol. 143, no. 3, pp. 489–492, 1984.
[40]
D. B. Kopans, “Migration of breast biopsy localization wire,” American Journal of Roentgenology, vol. 151, no. 3, pp. 614–615, 1988.
[41]
M. S. Sajid, U. Parampalli, Z. Haider, and R. Bonomi, “Comparison of radioguided occult lesion localization (ROLL) and wire localization for non-palpable breast cancers: a meta-analysis,” Journal of Surgical Oncology, 2011.
[42]
N. M. A. Krekel, B. M. Zonderhuis, H. B. A. C. Stockmann et al., “A comparison of three methods for nonpalpable breast cancer excision,” European Journal of Surgical Oncology, vol. 37, no. 2, pp. 109–115, 2011.
[43]
P. L. Giacalone, A. Bourdon, P. D. Trinh et al., “Radioguided occult lesion localization plus sentinel node biopsy (SNOLL) versus wire-guided localization plus sentinel node detection: a case control study of 129 unifocal pure invasive non-palpable breast cancers,” European Journal of Surgical Oncology, vol. 38, no. 3, pp. 222–229, 2012.
[44]
I. Thomassin-Naggara, L. Lalonde, J. David, E. Darai, S. Uzan, and I. Trop, “A plea for the biopsy marker: how, why and why not clipping after breast biopsy?” Breast Cancer Research and Treatment, vol. 132, pp. 881–893, 2012.
[45]
F. R. Margolin, L. Kaufman, S. R. Denny, R. P. Jacobs, and J. D. Schrumpf, “Metallic marker placement after stereotactic core biopsy of breast calcifications: comparison of two clips and deployment techniques,” American Journal of Roentgenology, vol. 181, no. 6, pp. 1685–1690, 2003.
[46]
F. R. Margolin, R. P. Jacobs, S. R. Denny, and J. D. Schrumpf, “Clip placement after sonographically guided percutaneous breast biopsy,” Breast Journal, vol. 9, no. 3, pp. 226–230, 2003.
[47]
P. R. Eby, K. E. Calhoun, B. F. Kurland et al., “Preoperative and intraoperative sonographic visibility of collagen-based breast biopsy marker clips,” Academic Radiology, vol. 17, no. 3, pp. 340–347, 2010.
[48]
J. Nurko, A. T. Mancino, E. Whitacre, and M. J. Edwards, “Surgical benefits conveyed by biopsy site marking system using ultrasound localization,” American Journal of Surgery, vol. 190, no. 4, pp. 618–622, 2005.
[49]
M. A. Gittleman, “Single-step ultrasound localization of breast lesions and lumpectomy procedure,” American Journal of Surgery, vol. 186, no. 4, pp. 386–390, 2003.
[50]
A. Luini, S. Zurrida, V. Galimberti, and G. Paganelli, “Radioguided surgery of occult breast lesions,” European Journal of Cancer, vol. 34, no. 1, pp. 204–205, 1998.
[51]
S. Monti, V. Galimberti, G. Trifiro et al., “Occult breast lesion localization plus sentinel node biopsy (SNOLL): experience with 959 patients at the European Institute of Oncology,” Annals of Surgical Oncology, vol. 14, no. 10, pp. 2928–2931, 2007.
[52]
R. S. Rampaul, R. D. MacMillan, and A. J. Evans, “Intraductal injection of the breast: a potential pitfall radioisotope occult lesion localization,” British Journal of Radiology, vol. 76, no. 906, pp. 425–426, 2003.
[53]
H. Medina-Franco, L. Abarca-Pérez, M. N. García-Alvarez, J. L. Ulloa-Gómez, C. Romero-Trejo, and J. Sepúlveda-Méndez, “Radioguided occult lesion localization (ROLL) versus wire-guided lumpectomy for non-palpable breast lesions: a randomized prospective evaluation,” Journal of Surgical Oncology, vol. 97, no. 2, pp. 108–111, 2008.
[54]
B. D. Fornage, M. I. Ross, S. E. Singletary, and D. D. Paulus, “Localization of impalpable breast masses: value of sonography in the operating room and scanning of excised specimens,” American Journal of Roentgenology, vol. 163, no. 3, pp. 569–573, 1994.
[55]
I. C. Bennett, J. Greenslade, and H. Chiam, “Intraoperative ultrasound-guided excision of nonpalpable breast lesions,” World Journal of Surgery, vol. 29, no. 3, pp. 369–374, 2005.
[56]
A. J. Potterton, D. J. Peakman, and J. R. Young, “Ultrasound demonstration of small breast cancers detected by mammographic screening,” Clinical Radiology, vol. 49, no. 11, pp. 808–813, 1994.
[57]
L. F. Smith, R. Henry-Tillman, S. Harms et al., “Hematoma-directed ultrasound-guided breast biopsy,” Annals of Surgery, vol. 233, no. 5, pp. 669–675, 2001.
[58]
M. Thompson, R. Henry-Tillman, A. Margulies et al., “Hematoma-directed ultrasound-guided (HUG) breast lumpectomy,” Annals of Surgical Oncology, vol. 14, no. 1, pp. 148–156, 2007.
[59]
F. D. Rahusen, A. H. Taets van Amerongen, P. J. van Diest, P. J. Borgstein, R. P. Bleichrodt, and S. Meijer, “Ultrasound-guided lumpectomy of nonpalpable breast cancers: a feasibility study looking at the accuracy of obtained margins,” Journal of Surgical Oncology, vol. 72, pp. 72–76, 1999.
[60]
N. M. Krekel, M. H. Haloua, A. M. L. Cardozo et al., “Intraoperative ultrasound guidance for palpable breast cancer excision (COBALT trial): a multicentre, randomised controlled trial,” The Lancet Oncology, vol. 14, pp. 48–54, 2013.
[61]
K. Esbona, Z. Li, and L. G. Wilke, “Intraoperative imprint citology and frozen section pathology for margin assessment in breast conservation surgery: a systematic review,” Annals of Surgical Oncology, vol. 19, no. 10, pp. 3236–3245.
[62]
C. E. Cox, M. Hyacinthe, R. J. Gonzalez et al., “Cytologic evaluation of lumpectomy margins in patients with ductal carcinoma in situ: clinical outcome,” Annals of Surgical Oncology, vol. 4, no. 8, pp. 644–649, 1997.
[63]
S. L. Blair, J. Wang-Rodriguez, M. J. Cortes-Mateos et al., “Enhanced touch preps improve the ease of interpretation of intraoperative breast cancer margins,” American Surgeon, vol. 73, no. 10, pp. 973–976, 2007.
[64]
A. Kobbermann, A. Unzeitig, X.-J. Xie et al., “Impact of routine cavity shave margins on breast cancer re-excision rates,” Annals of Surgical Oncology, vol. 18, no. 5, pp. 1349–1355, 2011.
[65]
J. C. Bolger, J. G. Solon, S. A. Khan, A. D. Hill, and C. P. Power, “A comparison of intra-operative margin management techniques in breast-conserving surgery: a standardised approach reduces the likelihood of residual disease without increasing operative time,” Breast Cancer, 2013.
[66]
R. Marudanayagam, R. Singhal, B. Tanchel, B. O'Connor, B. Balasubramanian, and I. Paterson, “Effect of cavity shaving on reoperation rate following breast-conserving surgery,” Breast Journal, vol. 14, no. 6, pp. 570–573, 2008.
[67]
J. Mook, R. Klein, A. Kobbermann et al., “Volume of excision and cosmesis with routine cavity shave margins technique,” Annals of Surgical Oncology, vol. 19, pp. 886–891, 2012.
[68]
E. H. Romond, E. A. Perez, J. Bryant et al., “Trastuzumab plus adjuvant chemotherapy for operable HER2-positive breast cancer,” The New England Journal of Medicine, vol. 353, no. 16, pp. 1673–1684, 2005.
[69]
A. E. Giuliano, L. McCall, P. Beitsch et al., “Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases: The American college of surgeons oncology group z0011 randomized trial,” Annals of Surgery, vol. 252, no. 3, pp. 426–432, 2010.
[70]
V. Galimberti, E. Botteri, C. Chifu et al., “Can we avoid axillary dissection in the micrometastatic sentinel node in breast cancer?” Breast Cancer Research and Treatment, vol. 131, no. 3, pp. 819–825, 2012.
[71]
I. Jatoi, “Surgical margins in lumpectomy for breast cancer,” The New England Journal of Medicine, vol. 367, pp. 1269–1270, 2012.
[72]
R. Arriagada, M. G. Lê, J.-M. Guinebretière, A. Dunant, F. Rochard, and T. Tursz, “Late local recurrences in a randomised trial comparing conservative treatment with total mastectomy in early breast cancer patients,” Annals of Oncology, vol. 14, no. 11, pp. 1617–1622, 2003.
[73]
G. Curigliano, C. Criscitiello, F. Andrè, M. Colleoni, and A. Di Leo, “Highlights from the 13th St Gallen International Breast Cancer Conference 2013. Access to innovation for patients with breast cancer: how to speed it up?” Ecancermedicalscience, vol. 7, article 299, 2013.
[74]
The American Society of Breast Surgeons, “Position statement on breast cancer lumpectomy margins,” 2013, https://www.breastsurgeons.org/statements/PDF_Statements/Lumpectomy_Margins.pdf.
[75]
S. W. Phillips, H. Gabriel, C. E. Comstock, and L. A. Venta, “Sonographically guided metallic clip placement after core needle biopsy of the breast,” American Journal of Roentgenology, vol. 175, no. 5, pp. 1353–1355, 2000.
