Wednesday, October 24, 2012

Missing the Mark

A recent study from England has demonstrated an unexpectedly high re-operation rate in women who undergo breast conservation treatment (BCT) for breast cancer.  One in five women (out of 55,000) who were treated with lumpectomy required another surgery to ensure clear margins in a retrospective study of the years 2005-2008.  Re-excision rates were noted to be associated with the presence of ductal carcinoma in situ (DCIS) in the specimens, an entity that can often be multifocal on presentation. 

I have always felt that BCT was generally performed a little too, um, conservatively, in my training years.  Tiny incisions and little golfball sized specimes just barely encompassing the localizing wire were the norm.  As long as the xray confirmed that the abnormal calcifications were "captured", the surgery was called a success.  But then the final pathology would come back and you'd find yourself operating a few weeks later on scarred, inflamed breast tissue for an awkward, inelegant re-excision.

The lesson from such a study is that we need to be more certain before proceeding to the operating room.  No surgeon wants to do two surgeries when one will do.  Perhaps this will expand the role of breast MRI (especially in younger women or when core needle biopsies show DCIS) and other preoperative imaging modalities.  But also the surgery itself needs to be technically better.  We've always used 2mm as the standard minimal margin for "adequate clearance".  2mm has always struck me as sort of sketchy.  My policy is to err on the side of caution.  My lumpectomy specimens are probably bigger than most.  My deep margin is always carried down to the pectoral fascia.  Sometimes an old fashioned quadrentectomy is indicated.  And it's never a bad idea to involve a plastic surgeon early in the process, even for BCT, if you feel the excisional surgery will require some element of modified reconstruction....      


Anonymous said...

I'm a surgical intern, just did a lumpectomy today, and was puzzling over the fact that we can just guestamate how much tissue to take around the wire. Have always been told that bct+rads works just as well as mastectomy, maybe that's true only if you include re-excisions as a success.

Either way, I'm also generally impressed with the cosmetic outcome. Hopefully were doing the right thing for the patients

Anonymous said...

also (I posted above), Great to have you back! I started reading you first or second year of medschool and I ended up in a surgical residency. cheers.