In Regard to Moran et al

Abstract

To the Editor: A consensus view on margins in breast-conserving surgery is to be welcomed ( 1 Moran M.S. Schnitt S.J. Giuliano A.E. et al. Society of Surgical Oncology - American Society for Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in stage I and II invasive breast cancer. Int J Radiation Oncol Biol Phys. 2014; 88: 553-564 Abstract Full Text Full Text PDF PubMed Scopus (270) Google Scholar ). The related meta-analysis of 33 studies and the earlier meta-analysis ( 2 Houssami N. Macaskill P. Marinovich M.L. et al. The association of surgical margins and local recurrence in women with early stage invasive breast cancer treated with breast conserving therapy: A metaanalysis. Ann Surg Oncol. 2014; 21: 717-730 Crossref PubMed Scopus (321) Google Scholar , 3 Houssami N. Macaskill P. Marionovich M.L. et al. Metaanalysis of the impact of surgical margins on local recurrence in women with early-stage invasive breast cancer treated with breast-conserving therapy. Eur J Cancer. 2010; 46: 3219-3232 Abstract Full Text Full Text PDF PubMed Scopus (272) Google Scholar ) showed that close margins conferred odds ratios of ipsilateral breast tumor recurrence of 1.74 and 1.80, respectively, which are significant compared with negative margins. The meta-analysis from Houssami et al ( 2 Houssami N. Macaskill P. Marinovich M.L. et al. The association of surgical margins and local recurrence in women with early stage invasive breast cancer treated with breast conserving therapy: A metaanalysis. Ann Surg Oncol. 2014; 21: 717-730 Crossref PubMed Scopus (321) Google Scholar ) demonstrated that when different thresholds for a negative margin were considered, 1 mm was as good as wider margins. The data on margins >0 mm were limited; nonetheless, “pairwise comparison between distance categories for negative margins (in the adjusted models) showed that the odds of LR were higher for studies using >0 mm relative to 5 mm (P=.021)” ( 2 Houssami N. Macaskill P. Marinovich M.L. et al. The association of surgical margins and local recurrence in women with early stage invasive breast cancer treated with breast conserving therapy: A metaanalysis. Ann Surg Oncol. 2014; 21: 717-730 Crossref PubMed Scopus (321) Google Scholar ). The logic of using no ink on tumor as a negative margin is described by the consensus panel and is based in part on the difficulties with analyzing and inking margins. These same issues would, however, have been present in all of the studies included in the meta-analysis. The consensus panel decided that given the excellent local control rates in NSABP B-06, which used no ink on tumor, they were willing to ignore the increased risk of local recurrence associated with close margins. We know of no data from NSABP B-06 that provide any data on margin width. In 52 lumpectomies designated by the hospital pathologists as having ink on tumor, agreement with the central review was present in only 16 (31%) ( 4 Fisher E.R. Sass R. Fisher C. et al. Pathologic findings from the National Surgical Adjuvant Breast Project (Protocol 6). Cancer. 1986; 57: 1717-1724 Crossref PubMed Scopus (358) Google Scholar ). An audit of B-06 margins reports that “the presence of residual tumor at the margins of the surgical specimen (positive margins), or its absence, after lumpectomy often could not be confirmed” ( 5 Christian M.C. McCabe M.S. Korn E.L. et al. The National Cancer Institute Audit of the National Surgical Adjuvant Breast and Bowel Project Protocol B-06. N Engl J Med. 1995; 333: 1469-1475 Crossref PubMed Scopus (56) Google Scholar ). 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 CancerInternational Journal of Radiation Oncology, Biology, PhysicsVol. 88Issue 3PreviewTo convene a multidisciplinary panel of breast experts to examine the relationship between margin width and ipsilateral breast tumor recurrence (IBTR) and develop a guideline for defining adequate margins in the setting of breast conserving surgery and adjuvant radiation therapy. Full-Text PDF In Reply to Dixon and ThomasInternational Journal of Radiation Oncology, Biology, PhysicsVol. 89Issue 5PreviewTo the Editor: In their letter, Dixon and Thomas take issue with the Society of Surgical Oncology-American Society for Radiation Oncology (SSO-ASTRO) margins consensus panel guideline of no tumor on ink (>0 mm) rather than 1 mm as a minimal negative margin (1, 2). They correctly described our recommendation as “based in part on the difficulties with analyzing and inking margins,” and substantiate this point themselves by citing pathologists' inability to verify 0-mm versus >0-mm margins in nearly 70% cases from a single institutional series (1). Full-Text PDF