Clinical investigation: breast
Predictors of reexcision findings and recurrence after breast conservation

Presented at ASTRO Annual Meeting, October 2002, New Orleans, and the San Antonio Breast Cancer Symposium, San Antonio, 2002.
https://doi.org/10.1016/S0360-3016(03)00740-5Get rights and content

Abstract

Purpose

To identify predictors of reexcision findings and local recurrence in the setting of breast-conserving therapy with radiation.

Methods

The records of 535 patients who underwent breast-conserving surgery followed by radiation for Stage I or II cancer between 1972 and 1996 were reviewed. The mean follow-up period for surviving patients without evidence of recurrence is 6 years. Various clinical and pathologic prognostic factors were examined for significance with regard to reexcision findings and recurrence rates. Pathologic margin status was classified as negative, close (≤2 mm), positive, or indeterminate.

Results

The pathologic margin status was the most important predictor of local recurrence. The freedom from local relapse (FFLR) at 6 years was 97% for patients with negative pathologic margins and 86% for all others (p < 0.0001). There was no significant difference in recurrence rates among patients with close, positive, or indeterminate margins. However, the use and sequencing of systemic therapy affected recurrence rates among these patients. For patients with close, positive, or indeterminate margins, the crude risk of local recurrence was 4% among patients who received tamoxifen or received chemotherapy integrated with or after radiation. The risk of local recurrence was 16–29% among the patients with close, positive, or indeterminate margins who did not receive systemic therapy or who received radiation after completion of chemotherapy. Local recurrence rates were low in patients with negative margins (2–8%) regardless of the use of systemic therapy or its timing. The presence or absence of residual disease at reexcision did not predict recurrence as long as the final margins were negative. Among patients who underwent reexcision before radiation, extensive intraductal component (EIC) (p = 0.0001) and young patient age (p = 0.03) were predictive of residual disease in the specimen. Patients with initially close margins and no EIC had a low risk of residual disease at the time of reexcision, as did patients older than age 65 without EIC.

Conclusion

Pathologic margin status is the most important predictor of local recurrence after breast conservation with radiation. Patient age and EIC were significant predictors of residual disease at reexcision. The use and timing of systemic therapy appear to influence the risk of local recurrence in patients who do not have negative lumpectomy margins.

Introduction

Several randomized trials have established the efficacy of breast-conserving surgery followed by radiation for Stage I and II breast cancer (1). However, outcome predictors for patients treated with breast conservation are important in defining optimal patient selection and surgical management. Various clinical and pathologic criteria have been proposed to have prognostic import for local recurrence, including patient age (5) margin status (6), extensive intraductal component (EIC) 10, 11, and lymphovascular invasion (3). The impact of systemic therapy 12, 13 and radiation dose 14, 15 has also been described.

In earlier work, we found margin status to be the most important predictor of local recurrence after breast conservation (16). However, many patients in that series had indeterminate margin status because of prevailing pathologic and surgical practices. This review updates results for previously reported patients and includes a larger number of patients with defined margin status using uniform criteria. The predictors of findings at reexcision are also examined.

Section snippets

Methods and materials

The records of 535 patients treated with breast-conserving radiotherapy (RT) at Stanford University or the Washington-Stanford Radiation Oncology Center between 1972 and 1996 for Stage I or II breast cancer were reviewed with Institutional Review Board approval. Clinical and pathologic data were recorded as previously described (16). Margin status was classified on the initial and reexcision specimens as positive when invasive or in situ disease was seen at an inked surgical margin, close when

Local recurrence

For the entire group of patients, the actuarial freedom from local recurrence (FFLR) at 6 years for patients with negative margins was 97% vs. 86% for close, positive, or indeterminate (non-negative) margins (p < 0.0001, Fig. 1). Excluding patients with indeterminate margin status, the FFLR was 97% vs. 87%, respectively. There was no significant difference in local recurrence rates among non-negative margins by type (Table 2). The actuarial FFLR for close margins was 78%, for indeterminate

Discussion

Breast-conserving surgery with radiation is an established treatment for early-stage breast cancer. The final pathologic margin status of the lumpectomy specimen is the most important factor determining local recurrence rates in the majority of reports. Although a “negative” inked surgical margin is advised, variation exists in general surgical practice and among cooperative group studies in terms of what is considered an acceptable margin in the setting of breast conservation.

Few studies have

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