EMiRATES
MEDiCAL
tssN-0250-6882
April
2005
Volume
Official Publication of the Emirates Medical Association
23 Number
1
Emirates Medical Joumal (2005): 23(l ): 4l-44
Original Article
Positive margins in breast biopsy remains a surgical challenge Maha Sid Ahmed Abdel Hadi; MBBS, FRCSI, FACS*, Hanan Misfer Al Ghamdi; MD+, Dalal Mohammed Al Tamimi; MD Department of Swgery+ and Patholog,,, King Fahd Hospital of the Universil.v, King Faisal University, DQmmqm, Kingdom of Saudi Arabia.
Abstrrct - Finding microscopicalb, positive margins after breast lumpectom! is generally an indication for
re-excision.
However, many re-excision results are inaccurate or negative, thus not contributifig to disease control but msy increase Patied morbidii.- This studl' s11gap15 to re-evaluate our experience if m(rstectouies vere justifed in positive or close uargins, ard to set standard guidelines in the mqnqgement. A 14 year revielt operative and histopathologt records for the period from 19902004 was conducted. All breast specimens reports with positive or close margins which underyent furlher re-excisions vere reviev,,ed. The total identified number wqs 127, size ranged between 3-5cm on gross specimen meosuremenl. Those reported v,,ith positive margins excisions were 75, while those with close margin reporls were 52 patients. All patients underwent re-exci' sion in fheform ofeither mastectoml or y'ide local excision based on the surgeon's preference. The histopathologt tissue revie$ revealed positive re-excisions in 67 (52.7%1, while 60 (47.2%o) patients were negqtive residual tumour out ofthese 40 were previousb) reported with close margins and 20 of the with posilive margins. Of the negalive re-ercisio,ls 27 Patients underwent mqsteclom)' \'hich v'as considered an over treatmenl for these )'oung patients.
In conclusion swgical margins remoin the
best predictor
inqccurate. Mastectomy ma1' be the onb, option in some locally advanced disease, multi-focal or high grade tumours.
of residua! disease in lhe breasl though they are occasionally to erqdicale the dise(tse )'el it should be resemed for those 'b'ith
cases
Keyw'ords: brezst cancer, mastectomy, surgical margins
2004 of operative and histopathology records of all breast biopsies with positive or close margins results was performed. Positive margins were defined as the presence of tumour cells at the cut edge of the specimen, while close margins were defined as 2mm tumour involvement from the cut edge. All patients were primarily evaluated by clinical examination, radiological evaluation and fine needle aspiration cytology (FNAC)/Core biopsy.
Mastectomy is slowly fading as a sole treatment option for breast cancer, from the early 1950's with all its
complications ranging from disfigurement to arm swellings and contraclures. Breast conserving surgery (BCS) has emerged and gained popularity in recent years as the treatment ofchoice for early breast cancer. It is effective for disease control with acceptable cosmetic results. The most recognized pitfall in this type of surgical treatment is the incomplete excision and residual tumour. The finding of microscopically posi tive margins is generally an indication for re-excision, however, many re-excisions results are with no detectable disease.' In this instance the re-excision does not contribute to disease control but does increase patient morbidity, cost and may compromise the cosmetic outcome.
Patients with positive margins underwent lumpectomy with gross safety margin of at least 2cm for both confirming the diagnosis and therapeutic excisions. Excised tumours were evaluated grossly for measure-
ments and histologically for pathologic features and margin involvement.
ヽ ′ ．
Results
Mastectomy still remains an option to locally advanced
cancers
for
those who elect
to
perform
iI
The total number ofpatients was 127 with an age range between 22-7lyrs ( mean age 4O.lyrs). Tumour size measured on gross specimens ranged between 3-5cm. 75 specimens were with positive margins and 52 were labeled as close to the margins. All patients underwent
for
prophylaxis.
Materials and Methods This retrospeclive study was undertaken al King Fahd Hospital ofthe University, Alkhobar, Eastem Province of Saudi Arabia. It is a tertiary care hospital with a capacity of 420 beds. A 14 year review from 1990-
re-excision in the form of mastectomy or local wide
excision. The results
of
salvage surgery were 67
(52.7%) which showed residual tumour in the excised
41
POSITIVEヽ lARCINSIN BREAST BIOPSY REMAINS A SURGlCAL CHALLENGE
pared to those treated with mastectomy (60%), differences was only noted in the rates of local-regional recurrence which was higher with BCT.'
Table I - Nlargin status follolr'ing surgert HIS´ ″ ″ο′ οα
ttrs′ ″ θ″αrla″
Second operalion -ve RD
RD 55 (',|!o/.',) 12 (23o/.) 61 (s2.7%) +ve
Positivc margins 75(591%)
Closc margins
52(409%)
Total
127
20 (260/0\ 40 (77o/o)
The identification of mammographically and clinically unsuspected multifocal or extensive residual tumour
60 (4',t.2%)
may lend support to modified radical mastectomy (MRM) rather than re-excision, however, false negative findings due to post surgical changes and false positive margins due to enhancement of granulation
* RD: Residual Disease Table 2-Negative result analysis Dお easc s″ ′ 〃s
Rθ ― excお
Rcsldual discasc
Negative RD
Tota1
tissue remain the limitation. On the other hand, MR imaging has a high positive predictive value for predicting residual tumour after excisional biopsy." Some studies have reported MR imaging showing peak value of 95% sensitivity and 92o/o positive predictive value were at 35 and 28 days after surgery respectively.'
Mos″ ξ″″l, "ll
13(76%)
23(46%)
36(28%)
64(831%) 27(54%) 91(72%)
specimens while 60 (47 .2o/o) were negative. Of the neg-
ative specimens (60), 20 were originally labeled as positive margins while 40 were with close to the margins (Table l).
FNAC and Tru-cut needle biopsies are still widely used for palpable breast lesions. In women with mammographicalty detected breast lesions, diagnosis with stereotactic core biopsy rather than wire localization reduces the amount oftissue removed to achieve negative surgical margins.'
Negative results from both mastectomy and local excision specimens were reviewed. These showed that the number of mastectomies performed in those discovered to fall into the negative residual disease group was 27, accounting for 54% ofthe disease free group, while local wide excision was performed only in 23 (46%) (Table 2). ln this series BCS was successful in 23 ( l80o) flrom the total number ofpatients.
Imprint cyology is an accurate, simple, rapid, and cost-effective method for determining the margin status ofbreast conservation therapy specimens intraoperatively, allowing a survey of the entire surface area of the lumpectomy specimen, which is not practical using frozen section evaluation. in addition it also overcomes the sampling error inherent in the frozen section analy-
Discussion Breast conserving therapy (BCT) has gained popularity in recent years as the treatment of choice for early breast cancer. It is effective for disease control with
sis.'rn
The presence of oestrogen receptor negative tumour with positive margins has a significantly higher rate of local recurrence as compared to oestrogen receptor negalive with clear margins and oestrogen receptor positive regardless ofthe margins.l' BCT and definitive breast irradiation can be used for selected patients with focally positive or close margins disease. The 8- year local control rates and survival are similar to those in patients with negative or unlnown margins.'r Negative resection margins are optimal, recent data suggests that chemotherapy may delay local recurrences beyond 5 years in positive or close margins.''
acceptable cosmetic results. Negative margins has become a pre-requisite for breast conserving surgery recognizing that positive margins may impacl negatively on local recurrence rates.' Surgical margin involvement usually results in obligatory re-excision or mastectomy. Patients with positive margins are 67 times more likely to undergo mastectomies than those with negalive margins.' However. many re-excisions are with no detectable disease, in this instance the reexcision does not contribute to disease control but increase patients morbidity, cost and compromise the cosmetic outcome.r
Neither mastectomy or breast conserving surgery have a significant prognostic impact on the overall survival
The identification of a subset of women with invasive breast cancer who might be spared the time, the expense and the potential complications of radiotherapy after lumpectomy remain the goal of clinical research.rr Other studies identified a subset of women (6%) with low risk of local recurrence. These women aged 50 years or older, with nodal involvement, lym-
or time to
subsequent local-regional recurrence. Regardless of the local therapy patients in whom early
local recurrence develops have poor
prognosis.'
Similar survival rates were noted after l3-year followup between groups treated with BCT (54%) as com-
42
Emirates Medical Joumal (2005): 23(l)
phovascular invasion or comedo ductal carcinoma insitu (DCIS) and had Estrogen receptor (ER)- positive tumours. Patients with these listed prognostic characteristics could be spared the cost, inconvenience and side effects of postoperative irradiation.rs However, some authors speculate until additional data in this subject is available. the use of breast conserving surgery without the addition of radiotherapy should be considered investigational.
the
inconvenience,
the time, cost and
cosmetic
procedures. as high as 5lolo ofpatients initially managed with BCT required additional surgery compared with l2o/o in the mastectomy group, despite
It has been reported that
this fact, breast conservation was ultimately successful in 957o ofpatients.'" The problem oflocal relapse in the conservatively treated breast is becoming increasingly common. A complicated array ofconfounding clinical, pathological and treatment factors contribute to this problem and may lead to apparent contradictions between series. In addition because of the protracted nature of the ipsilateral tumour recurrence follow-up time is a significant factor that must be accounted for in data analysis and interpretation.'- Large tumour size and tumour type such as invasive lobular cancer and ductal carcinoma in-situ were significant predictors of cavity margin status in relation to initial margin status. Complete cavity margin excision should avoid the need for further re-excision surgery in most patients where
With the increased use of BCT followed by radiotherapy, ipsilateral local recurrences are becoming a relatively a common problem. Identification ofrisk factors for local and systemic relapse and clarification of the interaction between local relapse and systemic disease are critical to our understanding of the narural history of the conservatively managed breasl cancer. Negative margin status identifies patients with a very low risk of ipsilateral tumour recurrence at 5 and l0 years after breasl conserving surgery while the risk of tumour recurrence with close margins is equal to or greater than for patients with positive margins, especially after re-excision. However, when re-excision of an initially close or positive margin results in a negative margin the risk of tumour recurrence is reduced to that of the initially negative margin. rr
initial specimen margin was positive.'* Nearly all authors agree on the fact that larger tumour size, and increasing tumour grade suggests a greater chance of detecting residual disease, in addition involved margins led to a greater risk of residual can-
Positive family history of breast cancer by itself is not apparently a risk factor for local recurrence after BCT. Although this may be different for patients who are genetically predisposed to the development of breast cancer, positive family history does not appear to be a contraindication for BCT.
cer.'n
In conclusion, surgical margins remains the best predictor of residual disease, however, they are occasionally inaccurate, and may not contribute to disease control, on the contrary may increase patient's morbidity, cost and in addition may compromise cosmetic outcome. However, the concem of leaving tumour behind is greater than performing the salvage surgery. Mastectomies however needed should be reserved for selected patients with large or multifocal tumours with unfavorable pathological and receptor characteristics.
In this srudy the number of patients reported with positive and close margins was 127 patients. Salvage surgery in the form of local re-excision or MRM was performed in all patients. The large number of mastectomies performed was predicted in many of these patients because of the delayed presentation. Yet, the results were alarming considering that most of the patients were in the young reproductive age group, 27 MRM were performed unnecessarily in those patients with the considered morbidity of added reconstructive surgery prolonged hospital stay, cost and delay in administration of adjuvant therapy. Decision for performing MRM was solely based on the tumour size which influenced the presence ofpositive or close margins rather than the overall evaluation the pathological
More studies with careful attention to selection factors including tumour size, pathologic features and estrogen receplor status may have a significant influence on predicting margin status and the rate of relapse. Close long term follow-up and adjuvant therapy may assist in disease assessment and control. References
l.
Papa t6'7
characteristics or the tumour receptor status. Therefore, we feel salvage surgery in the form oflocal re-excision when feasible rather that MRM would have been the treatment of choice in many of our cases sparing them
2.
MZ, Zippel D. Koller M.
-t7
43
Positive margins ofbreast 70..
t.
Klinberg VS. Harms S and Korourian S: Assessing margin status. Srrr
3.
er a,1:
biopsy: is re-excision necessary? J Sury Onc, 1999:
Orcol, 1999; E: 77-84.
Luu HH, Otis CN, Reed WP and Garb JI: The unsatisfactory
POSITIVE MARGINS IN BREAST BIOPSY REMAINS A SURCICAL CHALLENGE
margin
in
breast cancer surgery
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Van Tienhoben G, Voogd AC, Peterse JL, er al. Prognosis after treatment for loco-regional recufience after mastectomy or breast consewing therapy in two randomized rrials (EROTC l080land DBCG 82TM\. Eur J Cancer 1999; 35: 32-38.
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Van Dongen JA. Voogd AC, Fentiman IS, e1 .r/. Long-term results ofrandomized trial comparing breast conserving therapy with mastectomy: European organization of research and
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et
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1577-1584.
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Pass HA, et a/r Extent oflumpectomy for breast cancer after diagnosis by slerotacdc core versus locafization biopsy.,4nn Sur Oncol, 1999;6: 330-335.
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AJ. Shaw JA, Young PR and Geisinger
KR: Intraoperative evaluation of lumpectomy margins by imprint cyology with histologic correlation: a community hospital expeience. Arch Pathol Lab Med,2002i 126(7): 846-848.
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Weinberg E, Cox C, Dupont E, White L. e/ al. Local recurrence in lumpectomy patienls after imprint c,,tology margin evaluation. lm J S,r/g, 2004 : 188(4): 349-354. 11.
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a1:
Correspondence
MAHA ABDEL HADI, Consultant Surgeon
and
Asiociate Professor, Department of Surgery King Fahd Hospital of the University, P O Box 2208 Al-Khobar 31952, Kingdom ofSaudi Arabia. Tel: 0096655843710; Fax: 00966385815 l0 E-mail:
[email protected]
Surg, 20041 187(5):
643-646.
IL
B
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Freeman G, Fowble B, Hanlon A, e, d/. Patients with earlystage invasive caner with close or positive margins treated with conservative suryery and radiation have increased risk of breast recurrence that is delayed by adjuvant systemic therapy. Radia Oncol Bio Pht, 1999;,14: 1005-1015.
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a/. MR imaging ofthe breast in patients widr positive margins after lumpectomy: Influence ofthe time interval and MR imaging. AJR,2000:6,1
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44
Emirates Medical Journal is a beneficiary of an endowment from Sheikh Hamdan Bin Rashid Al Maktoum Award for Medical Sciences
LEl 「 ER丁0丁 HE
EDITOR
Accessory Breasts: When to Excise? To the Editor: Polymastia is a term used to describe the presence of more than two breasts in humans. It is synonymous with accessory, ectopic, or supernumerary breasts. It was once considered to be a symbol of increased fenility and femi-
continuing for 5 months after the surgery. The nonoperated group of 167 patients (727o) had follow-ups ranging from 1.5 to 10 years with no significant reported changes. Ectopic breast tissue includes supemumerary breasts and
(3.69Yo1 were clinically diagnosed as axillary accessory
aberrant breast tissue, most of which occur commonly along the embryonic milk line. Accessory axillary breast tissue is the most common type of polymastia accounting for 60-70Y" of all ectopic breast tissue (3). The true incidence of ectopic breast tissue is unknown, however, it is found more frequently in women than in men. Some series report an incidence of 2-6"/" in women. Although it is present at birth, it stays dormant until it is influenced by the female sex hqrmones during puberry, pregnancy, or lactation (4,5). Embryologically, at 5 weeks of gestation, the two to four cell layered ectodermal mammary streak develoPs on the trunk of the embryo. This streak extends from the axilla to the groin bilaterally on the ventral surface, called the mitk line (Hughes line). Most of it regresses, but a small amount remains bilaterally in the pecroral region. Failure to regress results in accessory breast tissue with a spectrum of varying degrees of clinical expression. In anenuated forms, it may be breast tissue wirh a nipple lacking an areola, glandular tissue with an areola but withouta nipple, oronly ectopic breast tissue with neither an areola or nipple (1,6). lt has also been teportid to occut
breast (Fig. 1),527" were bilateral. Only55 of233 patients
in locations outside the milk line, including the face,
(28%) underwent surgical excision. The majority of this group-39 patients (597o)-were concemed with cosmetic disfigurement, while 20 (30%) complained of mild pain and discomfort, with cyclic mastalgia accounting for 12 parients (60"/"1 in the symptomatic group; 6 (97")
posterior neck, chest, midback, buttock, vulva flank, hip, posterior and lateral aspects of the thigh, shoulder, and upper exrremities (7). Other reported locations include the parastemal subscapular and vulvar regions (5). Polymastia and polythelia (accessory nipples) can occur sporadicallyasdevelopmentalaccidenm, but familialcases have been reponed (8). Clinically they may be asymptomatic or cause cyclic discomfon, pain, restriction of arm movement, cosmetic problems, or anxiety (2).
niniry. Ancient goddesses of fenitity had a plethora of breasts arranged in neat rows on their torso (1).
Accessory breast is an infrequent clinical finding, with 0.4-6Y" (2), yet it is a concern in
a reported incidence of
a considerable number of women presenting to the out-
patient depanment. The majority are asymptomatic and many perceive it as pan of increased weight, however, orre-third of the patients are symPtomatic, particularly during menstruation and lactation, or are concerned with the cosmetic appearance. In this review we attempt to evaluate the need and iustification for routine excision. This retrospective review was undertaken at King Fahd Hospital from 1991 to 2003. All women with clinically diagnosed accessory breasts presenting to a singleconsultanr surgeon's clinic were included. Medical charts, outpatient records, operative notes, and pathology reports were reviewed.The follow-up period ranged form 18 monthsto 10 years.
During the study period, the total number of patients presenting with various breast complaints was 5314; 233
,
hc., lOTS-l22Xl0S t
Nn ba2,2ms IS'-t57
Symptoms
CGnElits co0cern fif,H pair/dscornh Maligmncy corrrn Abscess Tolal
No. ol palienls ０ ９ ２ ∞ ” ３
O 2oo' Akckl!.€ll Pn itlring. Thc Brcart lottuL volnft t
Table 1, Symptomatic Accrssory Breasts
” ” ６ １ “
and I 2"/"1 had an accessory breast abscess during lactarion (Table I ). Excised specimens included normal breast tissue, 41 (52.1%); fibrocystic disease, 14 (21.2"h1; fatty tissue, 6 (9.17"); chronic inflammation, 2 (3.1%); fibroadenoma, 1 (1.51%); duct ectasia, 1 (1.51%); and invasive ductal carcinoma, 1, (1.51%) (Table 2). Reported postoperative complications included wound infection in three patients (4.5%)and mild pain and discomfon in 5 patients (7.5%) feared malignancy
156
larrun ro nrE EDrroR
Ｌ ´
Table
.
2. Histopathology Results
Hislopalhobgy resuns
tlo. ol patrents
f\brmal breast lassue
41
621
FibrocFtc disees6s
14 6 2
2,2 91 31
Fatty lis.ere
Chrooic inflammalbn F'b.oaderDana Duai eclasia lfi/asare dLdal card,Dma Tolal
1 1 1
66
15, 151 151 1∞
The most common form of polythelia is the isolated presence of accessory nipples, but it can be a significant marker for other associated serious abnormalities. It is transmitted as an autosomal dominant trait with an incidence ranging from O-22/" to2.5Y".k typically presents as one or more small,wrinkled, pigmented areasalongthe
勝薔 魔 _￢
mammary line or beyond (9-1 1). A rare form of polythelia is linked with abnormalities in the urinary tract, such as obstructive uropathy orduplications. Nonrenal abnormalities such as cardiovascular, gasrrointestinal, and central nervous sy$em abnormaliries have also been reponed, in addition to chromosomal abnormalities and genetic syndromes (12). As normal breasr rissue, accessory breasts have the potential to undergo both benign and malignant changes' rherefore they require the same management strategies as for normally located breasts. As with any breast lesions, triple assessment in the form thorough clinicalexamination, radiologicevaluation by ultrasonography or mammography, and histologic/cyrologic analyses help determine the nature of the lesions. Mammography has successfully demon-
strated similarities between the axillary and remaining breast tissue; it is just separate from the bulk of the glandular parenchyma. Although the standard craniocaudal views do not demonstrate the radiologic findings, an exaggerated craniocaudal proiection that includes more ofthe axillary tissue is helpful, as are oblique views (13). Benign breast conditions such as fibrocystic disease, fibroadenoma, masdtis, and atypical ductal hyperplasia have all being reported (6). Mammary carcinoma arising in ectopic breast tissue is rare, accounting for 0.3% of all breast cancers. The majoriry have been located in axillary and vulvar ectopic breast tissuc. Most reported cases are ductalcarcinoma, but other rypes such as medullary, papillary, and lobular carcinoma have also been reported (14,15). In the current era of minimally invasive surgery, the extensive use of sentinel node biopsy has been successful
Figure
t.
(a) A 32-year-old pregnant !.,oman ptesented vyith an
enlarging axillary mass as she approach€d lull term. (b) Another vie with the arm abducted
n
in minimizing morbidity,
however, axillary histologic examination in cases ofbreast carcinoma may increase the chances of encountering tiny breast foci of ectopic breast tissue which may be interpreted as micrometastatic disease. An alternative solutioe to elarify the lymphatic drainage of accessory breasts, in the case of accessory breast cancer, is to adopt the use of lymphatic mapping, which allows for more accurate determinadon of lymph node status, cancer stage, and prognosis (16). To our knowledge, our series is the largest to be reported m date. Most our cases were incidentally discovered during routine clinical examination. The malority were concerned with cosmetic appearance. Those who were symptomatic demanded surgical excision, despite the explained minor risks of the nonsurgical approach. A discussion of the natural history of accessory breast and its histopathologic basis, which irrefutably demonstrates
レ ″″ ′ ο訪′Eピ llo″・
its benign nature, usually reduces the Patient's fear and any desire for surgical excision. Patients seeking surgical excision solely for cosmetic reasons should be well informed about the surgical morbidity and the possibility of scarring, and the decision for excision should be solely
theirs without pressure from the clinician. Outpatient liposuction should also be offered as an altemative to the classical approach because of its minimal scars and quick postoPerative recovery.
conclude from this study that it is important to ascertain the precise conccms of patients with accessory breasts. Each padent's concerns should be individualized and carefully addressed before a treatment plan is discussed. Routine surgical excision is not recommended. I0Ue
Hanan Alghamdi, MBBS' FSCS MBBS, FRCSI, FACS Abdelhadi, Maha Department of Surgery, Xing Fahd Hospital, King Faisal University, Dammam, Alkhobar, Saudi Arabia
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