- Once a patient undergoes breast-conserving surgery:
- The pathology report is reviewed to determine any need for additional surgery
- If the sentinel node biopsy was negative:
- No additional axillary surgery is warranted
- Margins assessed next:
- Historically, the definition of what was considered an adequate margin in patients undergoing breast-conserving surgery was left to the interpretation of the treating physicians
- In 2013, the Society of Surgical Oncology and the American Society for Radiation Oncology released consensus guidelines to assist physicians and patients in decisions regarding margins:
- These guidelines were based on:
- A meta-analysis of 33 studies evaluating in-breast tumor recurrence (IBTR) in relation to margin width
- The results of the meta-analysis reported:
- Positive margins were associated with 2-fold risk of IBTR:
- Routine re-excision is recommended for those patients
- For those with negative margins (defined as “no ink on tumor”), the meta-analysis reported that:
- Increasing margin widths were not associated with a reduction in IBTR.
- Positive margins were associated with 2-fold risk of IBTR:
- These guidelines were based on:
- Is the patient a candidate for adjuvant therapy?
- The 21-gene recurrence assay:
- Has been shown to accurately predict risk of distant recurrence and benefit of adjuvant chemotherapy:
- In women with ER positive tumors
- Has been shown to accurately predict risk of distant recurrence and benefit of adjuvant chemotherapy:
- Adjuvant chemotherapy is a category 1 recommendation for women with:
- ER negative tumors greater than 1 cm
- The 21-gene recurrence assay:
- Does this patient need genetic studies?
- The incidence of BRCA mutations in women with triple negative breast cancers:
- Ranges in the literature from 10% to 31%
- Current guidelines state that women who present with triple negative histology prior to age 60 should be considered for testing
- The incidence of BRCA mutations in women with triple negative breast cancers:
- References
- Moran MS, Schnitt SJ, Giuliano AE, Harris JR, Khan SA, Horton J, et al. Society of Surgical Oncology-American Society for Radiation Oncology consensus guideline on margins for breast-conserving surgery with whole breast irradiation in Stage I and II invasive breast cancer. Int J Radiat Oncol Biol Phys. 2014;88(3):553–564.
- Breast Cancer (version 1.2018). National Comprehensive Cancer Network website. https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Accessed October 18, 2019.
- Greenup R, Buchanan A, Lorizio W, Rhoads K, Chan S, Leedom T, et al. Prevalence of BRCA mutations among women with triple negative breast cancer in a genetic counseling cohort. Ann Surg Oncol. 2013;20:3254-3258.
- Genetic/Familial High Risk Assessment: Breast and Ovarian (version 2.2019). National Comprehensive Cancer Network website. https://www.nccn.org/professionals/physician_gls/pdf/genetics_screening.pdf. Accessed October 18, 2019.
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