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Surgical Margins in Breast Conservation

Surgical Margins in Breast Conservation HindawiPublishingCorporation InternationalJournalofSurgicalOncology Volume2013,ArticleID136387,2pages http://dx.doi.org/10.1155/2013/136387 Editorial SheldonMarcFeldman DivisionofBreastSurgery,VivianL.MilsteinAssociateProfessorofClinicalSurgery,CollegeofPhysiciansandSurgeons, ColumbiaUniversity,161FortWashingtonAvenue,10thFloor,Suite1005,NY10032,USA CorrespondenceshouldbeaddressedtoSheldonMarcFeldman;sf2388@columbia.edu Received27December2012;Accepted27December2012 Copyright©2013SheldonMarcFeldman. is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Signi�cantprogresshasbeenmadeinthediagnosisandtreat- breastconservation.eyincludediscussionofpreoperative mentofbreastcancerduringthepast30years.eincreased breast imaging, lesion localization, impact of tumor biology availability of screening mammography has resulted in a andsystemictherapy,intraoperativelesionidenti�cationand margin assessment techniques, the role of margin ablation higher percentage of woman being diagnosed with early stage disease allowing the option of breast conservation and oncoplastic techniques. ey also discuss the promise therapy to be more widely available. Long-term follow-up of ductal anatomy mapping toward the goal of validating studies clearly demonstrate equivalent survival with breast the “Sick lobe hypothesis” [7, 8] whichmayallowformore conservationsurgery(lumpectomy)andradiotherapyversus accurate identi�cation of breast tissue to be targeted for totalmastectomy[1,2,3].eimportanceofobtainingclear excision. lumpectomy surgical margins has been well established in R. Emmadi and E. L. Wiley provide an excellent review minimizing the risk of local recurrence [4]. Unfortunately from the pathology perspective of the different approaches there is a lack of uniform guidelines in terms of what to margin assessment. ey explore issues of specimen constitutes an adequately clear lumpectomy margin. Sub- processing,�xation,cuttingtechniques,andreporting. ey stantial debate about bigger margins being better continues wellexplainthereasonsforthereportingvariationsbetween institutionsandtheneedforstandardization. [5]. is has led to wide variations in lumpectomy margin reexcisionratesfrom15to47%[6].eseadditionalsurgical J.L.Bakeretal.presentascholarlyreviewofourcurrent procedures cause signi�cant patient distress, utilize health understanding of the issue of atypical ductal hyperplasia care resources, and can adversely affect cosmesis. From the (ADH) as it relates to surgical margins. ey highlight patient perspective, they may wonder why we did not get the large interobserver variability among pathologists in it right the �rst time. ey want their cancer gone while differentiatingADHfromlow-gradeductalcarcinomainsitu maintaininganormalappearance. (DCIS). e issue of whether ADH is a precursor lesion to is special issue highlights the areas of controversy DCISisexplored. anddemonstratescurrentbestpracticesandemergingnovel R. J. Rivera et al. report on a 21-site multicenter clin- approaches towards optimal breast conservation approach. ical trial evaluating the performance of the MarginProbe e goal is to improve our ability to provide breast- intraoperativedevice.isdeviceisbasedonradiofrequency conserving approaches for breast cancer while avoiding spectroscopy to assess adequacy of lumpectomy margins. multiple surgical procedures, minimizing recurrence risk eyanalyzedvolumeorresectionandreexcisionratesinthe while obtaining excellent cosmesis. We have chosen 6 of 16 device group versus usual surgical standard of care (SOC). submissionstobepublishedinthisspecialissue.Eachpaper ey demonstrate the reexcision rate of 14.1% in the device was evaluated by at least two expert reviewers and revised group versus 29.9% with SOC. Increased resection volume accordingtoreviewcomments. was2.6%usingthedevice. P. Ananthakrishnan et al. provide an excellent compre- M.M.Changetal.provideacomprehensiveoverviewof hensive review article on all aspects involved in optimizing oncoplasticbreastreduction.isisacompletereviewofthe 2 InternationalJournalofSurgicalOncology techniques including indication, patient selection, practical [7] T. Tot, “e theory of the sick breast lobe and the possible consequences,” International Journal of Surgical Pathology, vol. pointers,andtheirexperienceincludinga low(3.3%)rateof 15,no.4,pp.369–375,2007. margin failure. ey stress the importance of a coordinated team approach between breast surgical oncology, plastic [8] W.C.Dooley,“Breastductoscopyandtheevolutionoftheintra- surgery,breastimaging,andradiationoncology. ductal approach to breast cancer,” e Breast Journal, vol. 15, supplement1,pp.S90–S94,2009. Lastly, G. H. T. Au et al. present an exciting research paper on margin assessment using a Quantum-Dot Molec- ular probe in a mouse model. is employs nanoparticle monoclonal antibodies with molecular imaging. eir con- cept has a potential advantage over optical imaging and radiofrequencyspectroscopyinthatitisnotaffectedbytissue heterogeneity.Italsocandisplayanddifferentiateverysmall (100–200cells)spots.Timelineof30minutesispracticalfor intraoperative use. is early work is an highly innovative approachtoapracticalissue. ese papers present a great deal of important informa- tionandwellexplorethecurrentstateoftheart,controversies andfuturedirectionstowardstheimportantgoalofoptimiz- ing breast conservation with particular attention to margin issues. Acknowledgments My deepest appreciation to my coguest editors Drs. Anan- thakrishnan, Crowe, Dixon, and Fukuma; the authors, reviewers, and the leadership and staff of the International JournalofSurgicalOncologyforalltheireffortsandsupport tomakethisspecialissueareality. SheldonMarcFeldman References [1] B. Fisher, S. Anderson, J. Bryant et al., “Twenty-year follow- upofarandomizedtrialcomparingtotalmastectomy,lumpec- tomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer,” e New England Journal of Medicine, vol.347,no.16,pp.1233–1241,2002. [2] N.L.Simone,T.Dan,J.Shihetal.,“Twenty-�veyearresultsof the National Cancer Institute randomized breast conservation trial,”BreastCancerResearchandTreatment,vol.132,no.1,pp. 197–203,2012. [3] U. Veronesi, N. Cascinelli, L. Mariani et al., “Twenty-year follow-upofarandomizedstudycomparingbreast-conserving surgery with radical mastectomy for early breast cancer,” e New England Journal of Medicine, vol. 347, no. 16, pp. 1227–1232,2002. [4] S. E. Singletary, “Surgical margins in patients with early- stage breast cancer treated with breast conservation therapy,” AmericanJournalofSurgery,vol.184,no.5,pp.383–393,2002. [5] M. Morrow, J. R. Harris, and S. J. Schnitt, “Surgical margins in lumpectomy for breast cancer, bigger is not better,” e New EnglandJournalofMedicine,vol.367,pp.79–82,2012. [6] P.J.Lovrics,S.D.Cornacchi,F.Farrokhyaretal.,“erelation- ship between surgical factors and margin status aer breast- conservation surgery for early stage breast cancer,” American JournalofSurgery,vol.197,no.6,pp.740–746,2009. MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 International Journal of Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Research and Treatment Cellular Longevity Neurology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png International Journal of Surgical Oncology Hindawi Publishing Corporation

Surgical Margins in Breast Conservation

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Hindawi Publishing Corporation
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Copyright © 2013 Sheldon Marc Feldman. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Abstract

HindawiPublishingCorporation InternationalJournalofSurgicalOncology Volume2013,ArticleID136387,2pages http://dx.doi.org/10.1155/2013/136387 Editorial SheldonMarcFeldman DivisionofBreastSurgery,VivianL.MilsteinAssociateProfessorofClinicalSurgery,CollegeofPhysiciansandSurgeons, ColumbiaUniversity,161FortWashingtonAvenue,10thFloor,Suite1005,NY10032,USA CorrespondenceshouldbeaddressedtoSheldonMarcFeldman;sf2388@columbia.edu Received27December2012;Accepted27December2012 Copyright©2013SheldonMarcFeldman. is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Signi�cantprogresshasbeenmadeinthediagnosisandtreat- breastconservation.eyincludediscussionofpreoperative mentofbreastcancerduringthepast30years.eincreased breast imaging, lesion localization, impact of tumor biology availability of screening mammography has resulted in a andsystemictherapy,intraoperativelesionidenti�cationand margin assessment techniques, the role of margin ablation higher percentage of woman being diagnosed with early stage disease allowing the option of breast conservation and oncoplastic techniques. ey also discuss the promise therapy to be more widely available. Long-term follow-up of ductal anatomy mapping toward the goal of validating studies clearly demonstrate equivalent survival with breast the “Sick lobe hypothesis” [7, 8] whichmayallowformore conservationsurgery(lumpectomy)andradiotherapyversus accurate identi�cation of breast tissue to be targeted for totalmastectomy[1,2,3].eimportanceofobtainingclear excision. lumpectomy surgical margins has been well established in R. Emmadi and E. L. Wiley provide an excellent review minimizing the risk of local recurrence [4]. Unfortunately from the pathology perspective of the different approaches there is a lack of uniform guidelines in terms of what to margin assessment. ey explore issues of specimen constitutes an adequately clear lumpectomy margin. Sub- processing,�xation,cuttingtechniques,andreporting. ey stantial debate about bigger margins being better continues wellexplainthereasonsforthereportingvariationsbetween institutionsandtheneedforstandardization. [5]. is has led to wide variations in lumpectomy margin reexcisionratesfrom15to47%[6].eseadditionalsurgical J.L.Bakeretal.presentascholarlyreviewofourcurrent procedures cause signi�cant patient distress, utilize health understanding of the issue of atypical ductal hyperplasia care resources, and can adversely affect cosmesis. From the (ADH) as it relates to surgical margins. ey highlight patient perspective, they may wonder why we did not get the large interobserver variability among pathologists in it right the �rst time. ey want their cancer gone while differentiatingADHfromlow-gradeductalcarcinomainsitu maintaininganormalappearance. (DCIS). e issue of whether ADH is a precursor lesion to is special issue highlights the areas of controversy DCISisexplored. anddemonstratescurrentbestpracticesandemergingnovel R. J. Rivera et al. report on a 21-site multicenter clin- approaches towards optimal breast conservation approach. ical trial evaluating the performance of the MarginProbe e goal is to improve our ability to provide breast- intraoperativedevice.isdeviceisbasedonradiofrequency conserving approaches for breast cancer while avoiding spectroscopy to assess adequacy of lumpectomy margins. multiple surgical procedures, minimizing recurrence risk eyanalyzedvolumeorresectionandreexcisionratesinthe while obtaining excellent cosmesis. We have chosen 6 of 16 device group versus usual surgical standard of care (SOC). submissionstobepublishedinthisspecialissue.Eachpaper ey demonstrate the reexcision rate of 14.1% in the device was evaluated by at least two expert reviewers and revised group versus 29.9% with SOC. Increased resection volume accordingtoreviewcomments. was2.6%usingthedevice. P. Ananthakrishnan et al. provide an excellent compre- M.M.Changetal.provideacomprehensiveoverviewof hensive review article on all aspects involved in optimizing oncoplasticbreastreduction.isisacompletereviewofthe 2 InternationalJournalofSurgicalOncology techniques including indication, patient selection, practical [7] T. Tot, “e theory of the sick breast lobe and the possible consequences,” International Journal of Surgical Pathology, vol. pointers,andtheirexperienceincludinga low(3.3%)rateof 15,no.4,pp.369–375,2007. margin failure. ey stress the importance of a coordinated team approach between breast surgical oncology, plastic [8] W.C.Dooley,“Breastductoscopyandtheevolutionoftheintra- surgery,breastimaging,andradiationoncology. ductal approach to breast cancer,” e Breast Journal, vol. 15, supplement1,pp.S90–S94,2009. Lastly, G. H. T. Au et al. present an exciting research paper on margin assessment using a Quantum-Dot Molec- ular probe in a mouse model. is employs nanoparticle monoclonal antibodies with molecular imaging. eir con- cept has a potential advantage over optical imaging and radiofrequencyspectroscopyinthatitisnotaffectedbytissue heterogeneity.Italsocandisplayanddifferentiateverysmall (100–200cells)spots.Timelineof30minutesispracticalfor intraoperative use. is early work is an highly innovative approachtoapracticalissue. ese papers present a great deal of important informa- tionandwellexplorethecurrentstateoftheart,controversies andfuturedirectionstowardstheimportantgoalofoptimiz- ing breast conservation with particular attention to margin issues. Acknowledgments My deepest appreciation to my coguest editors Drs. Anan- thakrishnan, Crowe, Dixon, and Fukuma; the authors, reviewers, and the leadership and staff of the International JournalofSurgicalOncologyforalltheireffortsandsupport tomakethisspecialissueareality. SheldonMarcFeldman References [1] B. Fisher, S. Anderson, J. Bryant et al., “Twenty-year follow- upofarandomizedtrialcomparingtotalmastectomy,lumpec- tomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer,” e New England Journal of Medicine, vol.347,no.16,pp.1233–1241,2002. [2] N.L.Simone,T.Dan,J.Shihetal.,“Twenty-�veyearresultsof the National Cancer Institute randomized breast conservation trial,”BreastCancerResearchandTreatment,vol.132,no.1,pp. 197–203,2012. [3] U. Veronesi, N. Cascinelli, L. Mariani et al., “Twenty-year follow-upofarandomizedstudycomparingbreast-conserving surgery with radical mastectomy for early breast cancer,” e New England Journal of Medicine, vol. 347, no. 16, pp. 1227–1232,2002. [4] S. E. Singletary, “Surgical margins in patients with early- stage breast cancer treated with breast conservation therapy,” AmericanJournalofSurgery,vol.184,no.5,pp.383–393,2002. [5] M. Morrow, J. R. Harris, and S. J. Schnitt, “Surgical margins in lumpectomy for breast cancer, bigger is not better,” e New EnglandJournalofMedicine,vol.367,pp.79–82,2012. [6] P.J.Lovrics,S.D.Cornacchi,F.Farrokhyaretal.,“erelation- ship between surgical factors and margin status aer breast- conservation surgery for early stage breast cancer,” American JournalofSurgery,vol.197,no.6,pp.740–746,2009. MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 International Journal of Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Research and Treatment Cellular Longevity Neurology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Journal

International Journal of Surgical Oncology – Hindawi Publishing Corporation

Published: Jan 21, 2013

References

  • Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer,
    B. Fisher, S. Anderson, J. Bryant et al.
  • Twenty-five year results of the National Cancer Institute randomized breast conservation trial,
    N. L. Simone, T. Dan, J. Shih et al.
  • Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer,
    U. Veronesi, N. Cascinelli, L. Mariani et al.
  • Surgical margins in patients with early-stage breast cancer treated with breast conservation therapy,
    S. E. Singletary
  • Surgical margins in lumpectomy for breast cancer, bigger is not better,
    M. Morrow, J. R. Harris, and S. J. Schnitt
  • The relationship between surgical factors and margin status after breast-conservation surgery for early stage breast cancer,
    P. J. Lovrics, S. D. Cornacchi, F. Farrokhyar et al.
  • The theory of the sick breast lobe and the possible consequences,
    T. Tot
  • Breast ductoscopy and the evolution of the intra-ductal approach to breast cancer,
    W. C. Dooley