Annals of Surgical Oncology

, Volume 23, Issue 11, pp 3453–3458 | Cite as

Should New “No Ink On Tumor” Lumpectomy Margin Guidelines be Applied to Ductal Carcinoma In Situ (DCIS)? A Retrospective Review Using Shaved Cavity Margins

  • Andrea L. Merrill
  • Rong Tang
  • Jennifer K. Plichta
  • Upahvan Rai
  • Suzanne B. Coopey
  • Maureen P. McEvoy
  • Kevin S. Hughes
  • Michelle C. Specht
  • Michele A. Gadd
  • Barbara L. Smith
Breast Oncology



No consensus exists for clear margins for breast-conserving surgery for pure ductal carcinoma in situ (DCIS). We examined the implications of applying a “no ink on tumor” standard for pure DCIS by correlating clear margin width with rates of residual disease.


Lumpectomies with complete shaved cavity margins (SCMs) for pure DCIS at our institution from 2004 to 2007 were reviewed and patients with microinvasive cancer or multifocal disease requiring multiple wires excluded. Rates of residual disease in shaved margins were determined based on margin status of the main lumpectomy specimen using margin widths of “ink on tumor,” ≤1, >1 to <2, and ≥2 mm.


Overall, 182 women undergoing lumpectomy for pure DCIS met eligibility criteria. In patients with “ink on tumor” in the main lumpectomy specimen, 88 % had residual disease in the SCMs. Rates of residual disease in SCMs for lumpectomies with margins of <2 mm (but not on ink) were 52 % compared with 13 % for lumpectomies with margins ≥2 mm (p < 0.0005). Multivariate analyses confirmed the association of lumpectomy margin width and residual tumor in shaved cavity margins. Odds of residual disease in the SCM for postmenopausal patients were 74 % less than for pre/perimenopausal women (odds ratio 0.26; confidence interval 0.08–0.82).


Application of a “no ink on tumor” lumpectomy margin standard to patients with DCIS results in a significant increase in the rates of residual disease in cavity margins compared with use of a ≥2-mm margin standard. Use of narrower margins may have important implications for use of adjuvant therapy.


Residual Disease Margin Width Ipsilateral Breast Tumor Recurrence Shave Cavity Margin Comedo Necrosis 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



The authors have no conflicts of interest to disclose.


  1. 1.
    Bornstein BA, Recht A, Connolly JL, et al. Results of treating ductal carcinoma in situ of the breast with conservative surgery and radiation therapy. Cancer. 1991;67(1):7–13.CrossRefPubMedGoogle Scholar
  2. 2.
    Morrow M, Strom EA, Bassett LW, et al. Standard for the management of ductal carcinoma in situ of the breast (DCIS). CA Cancer J Clin. 2002;52(5):256–76.CrossRefPubMedGoogle Scholar
  3. 3.
    Kuske RR, Bean JM, Garcia DM, et al. Breast conservation therapy for intraductal carcinoma of the breast. Int J Radiat Oncol Biol Phys. 1993;26(3):391–6.CrossRefPubMedGoogle Scholar
  4. 4.
    Solin LJ, Kurtz J, Fourquet A, et al. Fifteen-year results of breast-conserving surgery and definitive breast irradiation for the treatment of ductal carcinoma in situ of the breast. J Clin Oncol. 1996;14(3):754–63.PubMedGoogle Scholar
  5. 5.
    Mirza NQ, Vlastos G, Meric F, et al. Ductal carcinoma-in situ: Long-term results of breast-conserving therapy. Ann Surg Oncol. 2000;7(9):656–64.CrossRefPubMedGoogle Scholar
  6. 6.
    Fisher B, Dignam J, Wolmark N, et al. Lumpectomy and radiation therapy for the treatment of intraductal breast cancer: Findings from National Surgical Adjuvant Breast And Bowel Project B-17. J Clin Oncol. 1998;16(2):441–52.PubMedGoogle Scholar
  7. 7.
    Silverstein MJ, Lagios MD, Groshen S, et al. The influence of margin width on local control of ductal carcinoma in situ of the breast. N Engl J Med. 1999;340(19):1455–61.CrossRefPubMedGoogle Scholar
  8. 8.
    Silverstein MJ, Lagios MD, Craig PH, et al. A prognostic index for ductal carcinoma in situ of the breast. Cancer. 1996;77(11):2267–74.CrossRefPubMedGoogle Scholar
  9. 9.
    Wapnir IL, Dignam JJ, Fisher B, et al. Long-term outcomes of invasive ipsilateral breast tumor recurrences after lumpectomy in NSABP B-17 and B-24 randomized clinical trials for DCIS. J Natl Cancer Inst. 2011;103(6):478–88.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Wang SY, Chu H, Shamliyan T, et al. Network meta-analysis of margin threshold for women with ductal carcinoma in situ. J Natl Cancer Inst. 2012;104(7):507–16.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Wang SY, Shamliyan T, Virnig BA, Kane R. Tumor characteristics as predictors of local recurrence after treatment of ductal carcinoma in situ: a meta-analysis. Breast Cancer Res Treat. 2011;127(1):1–14.CrossRefPubMedGoogle Scholar
  12. 12.
    Dillon MF, Mc Dermott EW, O’Doherty A, et al. Factors affecting successful breast conservation for ductal carcinoma in situ. Ann Surg Oncol. 2007;14(5):1618–28.CrossRefPubMedGoogle Scholar
  13. 13.
    Dillon MF, Maguire AA, McDermott EW, et al. Needle core biopsy characteristics identify patients at risk of compromised margins in breast conservation surgery. Mod Pathol. 2008;21(1):39–45.CrossRefPubMedGoogle Scholar
  14. 14.
    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(1):235–43.CrossRefPubMedGoogle Scholar
  15. 15.
    Morrow M, Jagsi R, Alderman AK, et al. Surgeon recommendations and receipt of mastectomy for treatment of breast cancer. JAMA. 2009;302(14):1551–6.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Azu M, Abrahamse P, Katz SJ, Jagsi R, Morrow M. What is an adequate margin for breast-conserving surgery? surgeon attitudes and correlates. Ann Surg Oncol. 2010;17(2):558–63.CrossRefPubMedGoogle Scholar
  17. 17.
    Dunne C, Burke JP, Morrow M, Kell MR. Effect of margin status on local recurrence after breast conservation and radiation therapy for ductal carcinoma in situ. J Clin Oncol. 2009;27(10):1615–20.CrossRefPubMedGoogle Scholar
  18. 18.
    Blair SL, Thompson K, Rococco J, et al. Attaining negative margins in breast-conservation operations: Is there a consensus among breast surgeons? J Am Coll Surg. 2009;209(5):608–13.CrossRefPubMedGoogle Scholar
  19. 19.
    Tartter PI, Kaplan J, Bleiweiss I, et al. Lumpectomy margins, reexcision, and local recurrence of breast cancer. Am J Surg. 2000;179(2):81-5.CrossRefPubMedGoogle Scholar
  20. 20.
    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. Int J Radiat Oncol Biol Phys. 2014;88(3):553–64.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Rizzo M, Iyengar R, Gabram SG, et al. The effects of additional tumor cavity sampling at the time of breast-conserving surgery on final margin status, volume of resection, and pathologist workload. Ann Surg Oncol. 2010;17(1):228–34.CrossRefPubMedGoogle Scholar
  22. 22.
    Narod SA, Iqbal J, Giannakeas V, Sopik V, Sun P. Breast cancer mortality after a diagnosis of ductal carcinoma in situ. JAMA Oncol. 2015;1(7):888–96.CrossRefPubMedGoogle Scholar
  23. 23.
    Esserman L, Yau C. Rethinking the standard for ductal carcinoma in situ treatment. JAMA Oncol. 2015;1(7):881–3.CrossRefPubMedGoogle Scholar
  24. 24.
    Sagara Y, Mallory MA, Wong S, et al. Survival benefit of breast surgery for low-grade ductal carcinoma in situ: a population-based cohort study. JAMA Surg. 2015;150(8):739–45.CrossRefPubMedGoogle Scholar
  25. 25.
    Hughes KS. DCIS does not need treatment…really? Breast Cancer Res Treat. 2015;154:1–4CrossRefPubMedGoogle Scholar
  26. 26.
    Faverly DR, Burgers L, Bult P, Holland R. Three-dimensional imaging of mammary ductal carcinoma in situ: Clinical implications. Semin Diagn Pathol. 1994;11(3):193–8.PubMedGoogle Scholar
  27. 27.
    Van Zee KJ, Subhedar P, Olcese C, Patil S, Morrow M. Relationship between margin width and recurrence of ductal carcinoma in situ: analysis of 2996 women treated with breast-conserving surgery for 30 years. Ann Surg. 2015;262(4):623–31.PubMedGoogle Scholar
  28. 28.
    Fisher ER, Dignam J, Tan-Chiu E, et al. Pathologic findings from the national surgical adjuvant breast project (NSABP) eight-year update of protocol B-17: intraductal carcinoma. Cancer. 1999;86(3):429–38.CrossRefPubMedGoogle Scholar
  29. 29.
    Hughes LL, Wang M, Page DL, et al. Local excision alone without irradiation for ductal carcinoma in situ of the breast: A trial of the eastern cooperative oncology group. J Clin Oncol. 2009;27(32):5319–24.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    McCormick B, Winter K, Hudis C, et al. RTOG 9804: a prospective randomized trial for good-risk ductal carcinoma in situ comparing radiotherapy with observation. J Clin Oncol. 2015;33(7):709–15.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Wong JS, Kaelin CM, Troyan SL, et al. Prospective study of wide excision alone for ductal carcinoma in situ of the breast. J Clin Oncol. 2006;24(7):1031–6.CrossRefPubMedGoogle Scholar
  32. 32.
    Wong JS, Chen YH, Gadd MA, et al. Eight-year update of a prospective study of wide excision alone for small low- or intermediate-grade ductal carcinoma in situ (DCIS). Breast Cancer Res Treat. 2014;143(2):343–50.CrossRefPubMedGoogle Scholar
  33. 33.
    Rauch GM, Hobbs BP, Kuerer HM, et al. Microcalcifications in 1657 patients with pure ductal carcinoma in situ of the breast: Correlation with clinical, histopathologic, biologic features, and local recurrence. Ann Surg Oncol. 2016;23(2):482–9.CrossRefPubMedGoogle Scholar
  34. 34.
    Merrill AL, Coopey SB, Tang R, et al. Implications of new lumpectomy margin guidelines for breast-conserving surgery: changes in reexcision rates and predicted rates of residual tumor. Ann Surg Oncol. 2016;23(3):729–34.CrossRefPubMedGoogle Scholar

Copyright information

© Society of Surgical Oncology 2016

Authors and Affiliations

  • Andrea L. Merrill
    • 1
  • Rong Tang
    • 1
    • 2
  • Jennifer K. Plichta
    • 1
  • Upahvan Rai
    • 1
  • Suzanne B. Coopey
    • 1
  • Maureen P. McEvoy
    • 1
  • Kevin S. Hughes
    • 1
  • Michelle C. Specht
    • 1
  • Michele A. Gadd
    • 1
  • Barbara L. Smith
    • 1
  1. 1.Division of Surgical OncologyMassachusetts General HospitalBostonUSA
  2. 2.Division of Breast Surgery, Hunan Cancer HospitalThe Affiliated Tumor Hospital of Xiangya Medical School of Central South UniversityChangshaChina

Personalised recommendations