Research Article

Re-Operation and Mastectomy Rates after Breast Conservative Surgery for Positive or Close Margins: A Review

Gilles Houvenaeghel1*, Eric Lambaudie1, Marie Bannier2, Sandrine Rua Ribeiro2, Julien Barrou2, Mellie Heinemann1, Max Buttarelli2 and Monique Cohen2
1Department of Surgical Oncology, Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille University, France
2Department of Surgical Oncology, Paoli Calmettes Institute, France


*Corresponding author: Gilles Houvenaeghel, Department of Surgical Oncology, Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille University, 232 Bd de Sainte Marguerite, 13009 Marseille, France


Published: 10 Oct, 2018
Cite this article as: Houvenaeghel G, Lambaudie E, Bannier M, Ribeiro SR, Barrou J, Heinemann M, et al. Re-Operation and Mastectomy Rates after Breast Conservative Surgery for Positive or Close Margins: A Review. Clin Surg. 2018; 3: 2149.

Abstract

Introduction: For positive or close margins after initial Breast Conservative Surgery (BCS) for Breast Cancer (BC), it is usually proposed re-operation with a second conservative surgery or mastectomy. We analyzed literature studies to determined re-operation rate and type of re-operation, differences according to treatment periods, histologic tumor type and results after initial BCS with oncoplasty.
Methods: We included 15 studies with highest numbers of patients treated from 2002 to 2016 and our institutional data from our institutional data base including patients treated from year 1995 to 2016. Re-operation rates and type of re-operation were determined for all studies, then according to successive treatment periods and different histologic tumor types. We specifically analyzed positive margins rates and positive or close margins rates for BCS with oncoplasty.
Results: Re-operation rate was 27.49% (CI 95% 27.4 to 27.6, range: 10.2% to 34%) among 402357 patients with BCS for DCIS or invasive BC with a decreased of re-operation rates among successive periods from 28.96% to 30.66% and 21.34%. Re-operation rates were higher for DCIS (33.1%) and lobular BC (40.6%). Mastectomy rate among patients with re-operation was 40.77% (CI 40.5 to 41.1, range: 10.7 to 62.1) and a third intervention for mastectomy was required for 13.5% of patients. We observed a decreased of mastectomy rates among successive periods from 59.62% to 48.8% and 36.81% with higher rate for lobular BC (70.5%). Positive margins rate after BCS with oncoplasty was 2.04% and close or positive margins were reported in 11.8%. Mastectomy rates for re-operation after BCS with oncoplasty were high (more than 60%).
Conclusion: Re-operation rate decrease progressively across successive and mastectomy rate also decrease progressively. Mastectomy rate is high for lobular invasive carcinoma and after initial resection with oncoplasty and patient’s information for a risk of a third operation with mastectomy should be done in case of re-operation.
Keywords: Mastectomy; Re-operation; Breast cancer; Margins


Introduction

For positive or close margins after initial Breast Conservative Surgery (BCS) for Breast Cancer (BC), it is usually proposed re-operation with a second conservative surgery or mastectomy. Guidelines for re-operation have evolved during previous years: for invasive BC, margins ≥ 5 mm, then 2 mm and then “no ink on tumor” were required and for Ductal Carcinoma In-Situ (DCIS), margins ≥ 2 mm are usually required but without clear consensus.
Re-operation rates for BCS are extremely variable across the literature. This is mainly due to no clear consensus regarding the definition of a “negative margin”, different preoperative and intraoperative tumor localizing methods, differences in intraoperative imaging techniques, specimen inking by surgeon or pathologist, the use of shave margins, tumor vs. lumpectomy size, surgeon volume of breast surgery per year, surgeon threshold to offer re-excision vs. mastectomy, patient’s choice informed of third re-operation risk and no post-mastectomy radiotherapy for patients without axillary lymph node macro-metastases [1], surgical possibility with oncoplasty for re-excision [2-4].
We analyzed literature studies to determined re-operation rate and type of re-operation, differences according to treatment periods, histologic tumor type and results after initial BCS with oncoplasty.


Table 1

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Table 1
Re-operation rate.

Table 2

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Table 2
Re-operation rates according to three periods.

Table 3

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Table 3
Re-operation rates for invasive breast cancer and ductal carcinoma insitu.

Methods

We included 15 studies with highest numbers of patients treated from 2002 to 2016 and our institutional data from our institutional data base including patients treated from year 1995 to 2016. Reoperation rates were determined for all studies, then according to treatment periods. Years of treatment were subdivided in three periods according to results reported in these studies: year 2005 and before, 2005-2010 and ≥ 2010. For some studies a minor crossover of years of treatment could be present. Re-operation rates were also analyzed for different histologic tumor types: DCIS, invasive carcinoma and different histology of invasive carcinomas, including ductal, lobular and others carcinomas.
Types of re-operation, re-excision and mastectomy rates were determined for all studies and also according to periods of treatment and histologic tumor types. A second re-operation with mastectomy could be required: rates of second mastectomy were also analyzed.
We specifically analyzed positive margins rates and positive or close margins rates for BCS with oncoplasty.
Results are presented with rates for each study and mean rates for all studies included in analysis, with confident interval 95% (CI 95) and range.


Table 4

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Table 4
Re-operation rates for ductal, lobular and others invasive breast cancers.

Table 5

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Table 5
Re-excisions and mastectomy rates.

Table 6

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Table 6
Re-excisions and mastectomy rates according to three periods.

Table 7

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Table 7
Re-excisions and mastectomy rates for invasive breast cancer and ductal carcinoma in-situ.

Table 8

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Table 8
Re-excisions and mastectomy rates for ductal, lobular and others invasive breast cancers.

Results

Re-operation rate was 27.49% (CI 95% 27.4 to 27.6, range: 10.2% to 34%) among 402357 patients with BCS for DCIS or invasive BC [3,5-18 and our institutional data’s] (Table 1).
When analysis of re-operation rates were performed according to three periods of treatment, we observed a decreased of re-operation rates among successive periods from 28.96% (4594/15861, CI 95% 28.3 to 29.7) to 30.66% (79708/259943, CI 30.5 to 30.8) and 21.34% (20016/93779, CI 21.1 to 21.6) [3,5-11,13-18 and our data] (Table 2). In study reported by Morrow et al. [13], surgery after initial lumpectomy declined by 16% (p<0.001) from 2013 to 2015.
Re-operation rates were different for invasive BC and DCIS, respectively in literature review 26.56% (86797/326828, CI 26.4 to 26.7, range: 10.4 to 30.5) and 33.1% (21594/65261, CI 32.7 to 33.5, range: 8.97 to 41.4) [5-7,11,17 and our data] (Table 3). However, re-operation rates differed between histologic types of invasive BC: 26.98% for ductal invasive BC, 40.6% for lobular invasive BC and 21.83% for others invasive histologic types [6 and our data] (Table 4).
Mastectomy rates among 108446 patients with re-operation in literature review were 40.77% (CI 40.5 to 41.1, range: 10.7 to 62.1) (Table 5) and 55.4% (CI 54.6 to 56.2) for studies with analysis of a third intervention for mastectomy (8309/14998) [5,7,10 and our data’s]. A third intervention for mastectomy had been reported in three studies [5,7,10] and our institutional data’s: mastectomy rate after re-excision was 13.54% (1059/7818, CI 12.8 to 14.3) (Table 5).
When analysis of mastectomy rates were performed according to three periods of treatment (DCIS and invasive), we observed a decreased of mastectomy rates among successive periods from 59.62% (2739/4594, CI 58.2 to 61.0) to 48.8% (2532/5191, CI 47.4 to 50.2) and 36.81% (6892/17903, CI 36.1 to 37.5) [7,8,10,11,14,15 and our data] (Table 6). In study reported by Wilke et al. [9] mastectomy rate was 37.9% for patients operated between 2004 and 2010.
Mastectomy rates were different according to histologic types of tumor: 49.7% (1960/3942, CI 48.1 to 51.3) for DCIS [3,5,8-10,12,15,17 and our data], 50.9% (9446/18566, CI 50.2 to 51.6) for invasive BC (Table 7) and respectively: 55.7% (CI 54.5 to 56.9) for ductal invasive BC, 70.5% (CI 68.3 to 72.7) for lobular invasive BC and 60.9% (CI 57.8 to 64.0) for others invasive histologic types [6 and our data], (Table 8).
After initial surgery with oncoplasty, close or positive margins was reported in 12.3% (342/2772, CI 11.1 to 13.5) in a meta-analysis reported in 2014 [19] and mastectomy rate for re-operation after initial resection with oncoplasty were high: 64% in Clough et al study [20] and 61.3% in Losken meta-analysis [19].
In literature review [21-53], positive margins rate after first conservative surgery with oncoplasty was 2.04% (69/3383, CI 1.6 to 2.5, range: 0 to 7.4) (Table 9). Close or positive margins after first conservative surgery with oncoplasty were reported in 11.8% (322/2730, CI 10.6 to 13.0, range: 2.0 to 18.9) and 12.3% (342/2772, CI 11.1 to 13.5) in a meta-analysis reported in 2014 (Table 10).


Discussion

Re-operation rates differ between studies from 10.2% to 34% in relation with several factors reported in introduction, mainly due to no clear consensus regarding the definition of sufficient margins, patient’s choice and tumor versus breast volume [3,4].
A decrease of re-operation rate was reported about 9% for absolute rate during the last period from year 2010 in comparison with older periods corresponding to 30% relative decreased. The higher re-operation rate was observed for lobular invasive BC, then for DCIS, with lesser rates for ductal invasive carcinomas and others histologic types (i.e., tubular, mucinous and medullar carcinomas).
For DCIS, the usual margin required is 2 mm. However, for DCIS, there was no statistical significant difference in Loco-Regional Recurrence (LRR) for patients with margins <2 mm vs. ≥ 2 mm who received radiotherapy, (10-year LRR 4.8% vs. 3.3%, respectively; p=0.72) [54]. One other large study evaluating the relationship between margin width and recurrence of did not identify a significant association of recurrence with margin width of ≤ 2 mm compared with larger margins for patients receiving radiotherapy [55]. However, Morrow et al. [56] reported in 2016 that 2 mm margin minimizes the risk of Ipsilateral Breast Tumor Recurrence (IBTR) compared with smaller negative margins, using a meta-analysis of margin width and IBTR from a systematic review.
It is also interesting to report that surgeons treating more than 50 BC annually were significantly more likely to report that margin with “no ink on tumor” was as adequate (85%) compared with those treating 20 cases or fewer (55%) (p<0.001) [13].
A conservative re-operation was possible for about 50% of patients with DCIS or ductal invasive BC and lesser for lobular invasive BC (about 30%) with a decrease of mastectomy rates among successive periods analyzed. Mastectomy rates decreased with an absolute rate of about 23% from the first to the last period, corresponding to 38% relative decreased. However, about 13% to 14% of patients need a third operation with mastectomy. This rate is important in order to inform patients of this risk when a re-excision is planned. As it was observed higher re-operation rate for lobular invasive carcinoma, mastectomy rate was also higher: about 10% absolute rate more and 20% increased relative risk. Finally, mastectomy rate after initial BCS with oncoplasty is high, more than 60%, due to impossibility of a new conservative surgery with acceptable cosmetic results and higher risk of local recurrence. However, for patients with BCS for invasive carcinomas and clear margins, the main factor of local recurrence was molecular-like tumor sub-type [57].


Table 9

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Table 9
Positives margins rates for initial surgery with oncoplasty.

Table 10

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Table 10
Closes or positives margins for initial surgery with oncoplasty.

Conclusion

Re-operation rate decrease progressively across successive periods (relative decrease of 30%) and mastectomy rate also decrease progressively (relative decrease of 38%). Consequently, a strong decrease of mastectomy rate was reported for an initial cohort of patients with BCS. In next year's, with more accurate pre-operative radiologic analysis, new techniques of per-operative margin analysis and application of guidelines with “no ink on tumor”, a decrease of re-operation rate and mastectomy rate is probable. This application of standard for adequate margins has the potential to improve cosmetic outcomes, and decrease health care costs. However, the mastectomy rate is high for lobular invasive carcinoma and after initial resection with oncoplasty and patient’s information for a risk of a third operation with mastectomy should be done in case of re-operation.


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