Can Radiation Therapy to the Breast Mitigate The Effect of a Positive Surgical Margin?

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • A meta-analysis demonstrated that a positive surgical margin (defined as the presence of invasive disease or ductal carcinoma in situ on ink):
    • Is associated with at least a twofold increase in the risk of ipsilateral breast tumor recurrence (odds ratio 1.96):
      • Which has been confirmed by other series
  • Although a boost may partially mitigate the effect of a positive surgical margin:
    • The risk of a local failure remains higher than in a patient with a cleared surgical margin treated with whole-breast irradiation
  • Furthermore, a randomized clinical trial showed that increasing the boost dose does not nullify the increased risk of local recurrence associated with a positive surgical margin (standard boost dose: 17.5% vs. increased boost dose: 10.8%, P>0.1):
    • This is true regardless of the type and fractionation pattern of the radiotherapy
  • Neither favorable tumor biology (including receptor status) nor the administration of systemic therapy:
    • Can completely offset the effect of a positive margin
  • The patient should be counseled on the higher rates of local recurrence:
    • With a known positive margin
  • American Society for Radiation Oncology (ASTRO) 2018 boost guidelines:
    • Recommend a boost for patients:
      • Less than 50 years
      • 51 years to 70 years old with:
        • High-grade disease or positive margins
  • Patients with positive margins are considered “unsuitable” by the ASTRO recommendations for accelerated partial breast radiation therapy
  • References
    • Houssami N, Macaskill P, Marinovich ML, Morrow M. The association of surgical margins and local recurrence in women with early-stage invasive breast cancer treated with breast-conserving therapy: a meta-analysis. Ann Surg Oncol. 2014;21(3):717-730.
    • DiBiase SJ, Komarnicky LT, Heron DE, Schwartz GF, Mansfield CM. Influence of radiation dose on positive surgical margins in women undergoing breast conservation therapy. Int J Radiat Oncol Biol Phys. 2002; 53(3):680-686.
    • Moran MS, Schnitt SJ, Giuliano AE, et al; Society of Surgical Oncology; American Society for Radiation Oncology. 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. J Clin Oncol. 2014;32(14):1507-1515.
    • Barelink H, Maingon P, Poortmans PM, et al. Whole-breast irradiation with or without a boost for patients treated with breast-conserving surgery for early breast cancer: 20-year follow-up of a randomised phase 3. Lancet Oncol. 2015;16(1):47-56.
    • Smith BD, Bellon JR, Blitzblau R, et al. Radiation therapy for the whole breast: executive summary of an American Society for Radiation Oncology (ASTRO) evidence-based guideline. Pract Radiat Oncol. 2018;8(3):145-152.
    • Correa C, Harris EE, Leonardi MC, et al. Accelerated partial breast irradiation: executive summary for the update of an ASTRO evidence-based consensus statement. Pract Radiat Oncol. 2017;7(2):73-79.
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Published by Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

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