Abstract
BackgroundControversy exists regarding the optimal negative margin width for ductal carcinoma in situ (DCIS) treated with breast-conserving surgery and whole-breast irradiation (WBRT).MethodsA multidisciplinary consensus panel used a meta-analysis of margin width and ipsilateral breast tumor recurrence (IBTR) from a systematic review of 20 studies including 7883 patients and other published literature as the evidence base for consensus.ResultsNegative margins halve the risk of IBTR compared with positive margins defined as ink on DCIS. A 2 mm margin minimizes the risk of IBTR compared with smaller negative margins. More widely clear margins do not significantly decrease IBTR compared with 2 mm margins. Negative margins less than 2 mm alone are not an indication for mastectomy, and factors known to impact rates of IBTR should be considered in determining the need for re-excision.ConclusionThe use of a 2 mm margin as the standard for an adequate margin in DCIS treated with WBRT is associated with low rates of IBTR and has the potential to decrease re-excision rates, improve cosmetic outcome, and decrease health care costs. Clinical judgment should be used in determining the need for further surgery in patients with negative margins < 2 mm.
Highlights
Negative margins halve the risk of ipsilateral breast tumor recurrence (IBTR) compared with positive margins defined as ink on ductal carcinoma in situ (DCIS)
A 2 mm margin minimizes the risk of IBTR compared with smaller negative margins
More widely clear margins do not significantly decrease IBTR compared with 2 mm margins
Summary
Breast-conserving therapy (BCT), defined as surgical excision of the primary tumor with a margin of surrounding normal tissue followed by whole-breast radiation therapy (WBRT), results in long-term cause-specific survival rates of greater than 95% for women with ductal carcinoma in situ (DCIS) as demonstrated in both randomized trials[1] and observational studies.[2,3] the addition of WBRT to surgical excision does not improve survival, it substantially reduces rates of ipsilateral breast tumor recurrence (IBTR), even among patients with small, non-high–grade DCIS.[1,4] In the four early randomized trials of WBRT for DCIS, microscopically clear margins defined as no ink on tumor were required in three studies,[5,6,7] but not in the fourth.[8]. Retrospective single-institution studies have suggested that a negative margin width of 1 cm or more may eliminate the reduction in IBTR seen with WBRT,[9] leading some to conclude that larger margins are beneficial in patients receiving WBRT. Despite the widespread use of BCT for DCIS, there is still no consensus on what constitutes an optimal negative margin width.[10] As a consequence, approximately one in three women attempting BCT for DCIS undergo a re-excision.[11] Re-excisions have the potential for added discomfort, surgical complications, compromise in cosmetic outcome, additional stress for patients and families, and increased health care costs, and have been associated with conversion to bilateral mastectomy.[12]. Controversy exists regarding the optimal negative margin width for ductal carcinoma in situ (DCIS) treated with breast-conserving surgery and whole-breast irradiation (WBRT)
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