Journal of Surgical Oncology 58:231-232 (1995)

Commentary

The goal of breast-conserving surgery and irradiation is to minimize local recurrence while preserving a good cosmetic appearance of the breast. Assessment of the margins of resection is one technique for evaluating the extent of residual tumor at the primary tumor site. Mok- be1 et al. [ 11 have demonstrated that positive margins are associated with residual tumor in 56% of cases, a finding similar to the 45% rate that we and others have reported 12-41 f

However, we have found the need for re-excision to be relatively uncommon after a properly planned diagnostic lumpectomy. In a series of 173 consecutive women un- dergoing a conservative diagnostic lumpectomy re-exci- sion for positive margins was necessary in only 5.4% [2]. We employ a number of technical maneuvers to allow complete tumor excision in a minimal volume specimen. First, we routinely use spot magnification views to define the extent of microcalcifications. Although the extent of calcification on standard two-view mammography corre- lates well with the extent of high-grade or comedo ductal carcinoma in situ (DCIS), the extent of low-grade DCIS is not well predicted by the use of standard mammogra- phy [ S ] . The use of magnification views has been shown to greatly improve the correlation between the mammo- graphic and pathologic extent of DCIS [ 5 ] , allowing the surgeon to plan an operation of appropriate magnitude.

When localization is undertaken, the procedure is greatly facilitated by placing the incision over the area of pathology rather than at the skin entry point of the local- izing wire. This allows the use of a small cosmetically acceptable incision while still providing good visualiza- tion of the wire and is particularly important when the wire takes a long path through the breast (Fig. 1). Inci- sion placement is facilitated by marking the wire entry site with a radiopaque marker and incision placement is then estimated after reviewing both mammographic views. We prefer the use of a hook wire with a thickened portion at the distal end. The radiologist positions the wire so that the lesion is distal to the thickened portion of the wire. After the incision is made, the breast tissue is incised until the change in caliber of the wire is exposed (Fig. 2). Excision is begun at this point, and the amount of tissue removed is guided by the extent of the mammo- graphic abnormality. The surgeon reviews the specimen radiograph, and if a suspicious lesion is seen to abut the edge of the specimen a limited re-excision of that area is undertaken as part of the initial surgery. We employ two wires for localization only when large areas of calcifica-

Fig. 1. traverses a long path through the breast.

Incision placement distally along localizing wire when wire

Fig. 2. incision of the breast parenchyma.

Identification of the wire within the substance of the breast by

tion are present and the patient is still considered a candi- date for breast-conserving therapy.

The high numbers of re-excisions performed by Mok- be1 et al. [ l ] is in part related to their definition of a

0 1995 Wiley-Liss, Inc.

232 Morrow

positive margin as tumor within 1 cm of the edge of the resected specimen. The incidence of positive margins varies with the definition of margins used and the tech- nique of pathologic examination employed. There is no consensus on what is the optimum distance from the tumor to the edge of the surgical specimen. The routine use of very large resections such as quandrantectomy results in a low rate of local recurrence, but this is ob- tained at the expense of cosmetic outcome [6]. We prefer to approach our patients with a limited excision. Re- excision is reserved for those with tumor touching the inked margins or cases with an extensive intraductal com- ponent where the risk of a heavy burden of residual DCIS surrounding the primary tumor site is high.

Monica Morrow, PhD

Northwestern University Medical School Chicago, Illinois 606 1 1

REFERENCES 1. Mokbel K, Ahmed M , Nash A, Sacks N: Reexcision operations in

nonpalpable breast cancer. J Surg Oncol58:225-228, 1995. 2. Kearney TJ, Morrow M: The need for re-excision does not ad-

versely affect the success of breast conserving surgery. Ann Surg Oncol (in press), 1995.

3. Schnitt SJ, Connolly JL, Kettry U, et al.: Pathologic findings on re-excision of the primary site in breast cancer patients considered for treatment by primary radiation therapy. Cancer 59:675--681, 1987.

4. Anscher MS, Jones P, Prosnitz LR, et al.: Local failure and margin status in early stage breast carcinoma treated with conservation surgery and radiation therapy. Ann Surg 281:22-28. 1993.

5 . Holland R, Hendricks JHCL: Microcalcifications associated with ductal carcinoma in situ: Mammographic-pathologic correlation. Semin DiagnPathol 11:181-192, 1994.

6. Veronesi U, Voterrani F, Luini A, et al.: Quadrantectomy versus lumpectomy for small size breast cancers. Eur J Cancer 26:671- 673, 1990.

7. Holland R, Connolly JI, Gelman R: The presence of an extensive intraductal component following a limited excision correlates with prominent residual disease in the remainder of the breast. J Clin Oncol8:113-118, 1990.