Annals of Surgical Oncology

, Volume 20, Issue 13, pp 4103–4112 | Cite as

Incidence and Consequence of Close Margins in Patients with Ductal Carcinoma-In Situ Treated with Mastectomy: Is Further Therapy Warranted?

  • Elizabeth FitzSullivan
  • Sara A. Lari
  • Benjamin Smith
  • Abigail S. Caudle
  • Savitri Krishnamurthy
  • Anthony Lucci
  • Elizabeth A. Mittendorf
  • Gildy V. Babiera
  • Dalliah M. Black
  • Jamie L. Wagner
  • Isabelle Bedrosian
  • Wendy Woodward
  • Sarah M. Gainer
  • Rosa Hwang
  • Funda Meric-Bernstam
  • Kelly K. Hunt
  • Henry M. Kuerer
Breast Oncology

Abstract

Background

The impact of close margins in patients with ductal carcinoma-in situ (DCIS) treated with mastectomy is unclear; however, this finding may lead to a recommendation for postmastectomy radiotherapy (PMRT). We sought to determine the incidence and consequences of close margins in patients with DCIS treated with mastectomy.

Methods

The records of 810 patients with DCIS treated with mastectomy from 1996 through 2009 were reviewed. Clinical and pathologic factors were analyzed with respect to final margin status. Median follow-up was 6.3 years.

Results

Overall, 94 patients (11.7 %) had close margins (positive, n = 5; negative but ≤1 mm, n = 54; 1.1–2.9 mm, n = 35). Independent risk factors for close margins included multicentricity, pathologic lesion size ≥1.5 cm, and necrosis, but not age, use of skin-sparing mastectomy, or immediate reconstruction (p > 0.05). Seven patients received PMRT, and none had a locoregional recurrence (LRR). Among the remaining 803 patients, the 10-year LRR rate was 1 % (5.0 % for margins ≤1 mm, 3.6 % for margins 1.1–2.9 mm, and 0.7 % for margins ≥3 mm [p < 0.001]). The 10-year rate of contralateral breast cancer was 6.4 %. On multivariate analysis, close margins was the only independent predictor of LRR (p = 0.005).

Conclusions

Close margins occur in a minority of patients undergoing mastectomy for DCIS and is the only independent risk factor for LRR. As the LRR rate in patients with close margins is low and less than the rate of contralateral breast cancer, PMRT is not warranted except for patients with multiple close/positive margins that cannot be surgically excised.

Keywords

Positive Margin Margin Status Contralateral Breast Cancer Contralateral Prophylactic Mastectomy Bilateral Breast Cancer 

Notes

Acknowledgment

The University of Texas MD Anderson Cancer Center is supported in part by the National Institutes of Health through Cancer Center Support Grant CA016672. The authors thank Stephanie Deming for editorial assistance.

Disclosures

The authors declare no conflict of interest.

References

  1. 1.
    Kuerer HM, Albarracin CT, Yang WT, et al. Ductal carcinoma in situ: state of the science and roadmap to advance the field. J Clin Oncol. 2009;27:279–88.PubMedCrossRefGoogle Scholar
  2. 2.
    Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2008. CA Cancer J Clin. 2008;58:71–96.PubMedCrossRefGoogle Scholar
  3. 3.
    Burstein HJ, Polyak K, Wong JS, Lester SC, Kaelin CM. Ductal carcinoma in situ of the breast. N Engl J Med. 2004;350:1430–41.PubMedCrossRefGoogle Scholar
  4. 4.
    Baxter NN, Virnig BA, Durham SB, Tuttle TM. Trends in the treatment of ductal carcinoma in situ of the breast. J Natl Cancer Inst. 2004;96:443–8.PubMedCrossRefGoogle Scholar
  5. 5.
    Smith GL, Smith BD, Haffty BG. Rationalization and regionalization of treatment for ductal carcinoma in situ of the breast. Int J Radiat Oncol Biol Phys. 2006;65:1397–403.PubMedCrossRefGoogle Scholar
  6. 6.
    Silverstein MJ, Barth A, Poller DN, et al. Ten-year results comparing mastectomy to excision and radiation therapy for ductal carcinoma in situ of the breast. Eur J Cancer. 1995;31A:1425–7.PubMedCrossRefGoogle Scholar
  7. 7.
    Silverstein MJ, Lagios MD, Martino S, et al. Outcome after invasive local recurrence in patients with ductal carcinoma in situ of the breast. J Clin Oncol. 1998;16:1367–73.PubMedGoogle Scholar
  8. 8.
    Schouten van der Velden AP, van Vugt R, Van Dijck JA, Leer JW, Wobbes T. Local recurrences after different treatment strategies for ductal carcinoma in situ of the breast: a population-based study in the East Netherlands. Int J Radiat Oncol Biol Phys. 2007;69:703–10.PubMedCrossRefGoogle Scholar
  9. 9.
    Meijnen P, Oldenburg HS, Peterse JL, Bartelink H, Rutgers EJ. Clinical outcome after selective treatment of patients diagnosed with ductal carcinoma in situ of the breast. Ann Surg Oncol. 2008;15:235–43.PubMedCrossRefGoogle Scholar
  10. 10.
    Lee LA, Silverstein MJ, Chung CT, et al. Breast cancer-specific mortality after invasive local recurrence in patients with ductal carcinoma-in situ of the breast. Am J Surg. 2006;192:416–9.PubMedCrossRefGoogle Scholar
  11. 11.
    Carlson GW, Page A, Johnson E, Nicholson K, Styblo TM, Wood WC. Local recurrence of ductal carcinoma in situ after skin-sparing mastectomy. J Am Coll Surg. 2007;204:1074–8.PubMedCrossRefGoogle Scholar
  12. 12.
    Chan LW, Rabban J, Hwang ES, et al. Is radiation indicated in patients with ductal carcinoma in situ and close or positive mastectomy margins? Int J Radiat Oncol Biol Phys. 2011;80:25–30.PubMedCrossRefGoogle Scholar
  13. 13.
    Godat LN, Horton JK, Shen P, Stewart JH, Wentworth S, Levine EA. Recurrence after mastectomy for ductal carcinoma in situ. Am Surg. 2009;75:592–5.PubMedGoogle Scholar
  14. 14.
    Kelley L, Silverstein M, Guerra L. Analyzing the risk of recurrence after mastectomy for DCIS: a new use for the USC/Van Nuys Prognostic Index. Ann Surg Oncol. 2011;18:459–62.PubMedCrossRefGoogle Scholar
  15. 15.
    Childs SK, Chen YH, Duggan MM, et al. Impact of margin status on local recurrence after mastectomy for ductal carcinoma in situ. Int J Radiat Oncol Biol Phys. 2013;85:948–52.PubMedCrossRefGoogle Scholar
  16. 16.
    Chadha M, Portenoy J, Boolbol SK, Gillego A, Harrison LB. Is there a role for postmastectomy radiation therapy in ductal carcinoma in situ? Int J Surg Oncol. 2012;2012:423520.PubMedGoogle Scholar
  17. 17.
    Lari SA, Kuerer HM. Biological markers in DCIS and risk of breast recurrence: a systematic review. J Cancer. 2011;2:232–61.PubMedCrossRefGoogle Scholar
  18. 18.
    Rashtian A, Iganej S, Amy Liu IL, Natarajan S. Close or positive margins after mastectomy for DCIS: pattern of relapse and potential indications for radiotherapy. Int J Radiat Oncol Biol Phys. 2008;72:1016–20.PubMedCrossRefGoogle Scholar
  19. 19.
    Owen D, Tyldesley S, Alexander C, et al. Outcomes in patients treated with mastectomy for ductal carcinoma in situ. Int J Radiat Oncol Biol Phys. 2012;85:129–34.CrossRefGoogle Scholar
  20. 20.
    Mallon PT, McIntosh SA. Post mastectomy radiotherapy in breast cancer: a survey of current United Kingdom practice. J BUON. 2012;17:245–8.PubMedGoogle Scholar
  21. 21.
    Kim JH, Tavassoli F, Haffty BG. Chest wall relapse after mastectomy for ductal carcinoma in situ: a report of 10 cases with a review of the literature. Cancer J. 2006;12:92–101.PubMedGoogle Scholar

Copyright information

© Society of Surgical Oncology 2013

Authors and Affiliations

  • Elizabeth FitzSullivan
    • 1
  • Sara A. Lari
    • 1
  • Benjamin Smith
    • 2
  • Abigail S. Caudle
    • 1
  • Savitri Krishnamurthy
    • 3
  • Anthony Lucci
    • 1
  • Elizabeth A. Mittendorf
    • 1
  • Gildy V. Babiera
    • 1
  • Dalliah M. Black
    • 1
  • Jamie L. Wagner
    • 1
  • Isabelle Bedrosian
    • 1
  • Wendy Woodward
    • 2
  • Sarah M. Gainer
    • 1
  • Rosa Hwang
    • 1
  • Funda Meric-Bernstam
    • 1
  • Kelly K. Hunt
    • 1
  • Henry M. Kuerer
    • 1
  1. 1.Department of Surgical OncologyThe University of Texas MD Anderson Cancer CenterHoustonUSA
  2. 2.Department of Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonUSA
  3. 3.Department of PathologyThe University of Texas MD Anderson Cancer CenterHoustonUSA

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