December 2012

Surgical margins in lumpectomy specimens

In the article about margins in lumpectomy specimens (October 2012), Stuart Schnitt, MD, seems to imply that as long as there is no tumor on ink, the excision is adequate. Certainly this is in stark contrast to the situation in malignant melanoma of the skin where the recommendation is a 1-cm margin for lesions deeper than 1 mm. Not to call the margin positive when tumor is one collagen fiber away from the ink seems to be ludicrous. As a practicing surgical pathologist it is hard for me to believe that one can be certain that no tumor remains with such minimal clearance. After all, we don’t do step sections to ascertain that at no point in the excision specimen is tumor “on ink.” There seems to be too much faith in the ability of radiation and anti-cancer drugs to prevent local recurrence. We also seem to have forgotten that the original studies showing no difference in survival between mastectomy and breast conservation surgery were for tumors less than 2 cm. We routinely see much larger tumors in lumpectomy specimens, sometimes to the point where one wonders how much of the breast is left.

Reference

Veronesi U, Cascinelli N, Mariani L, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med. 2002;347:1227–1232.

Arthur H. Mensch, MD
West River, MD

Stuart J. Schnitt, MD, director of anatomic pathology at Beth Israel Deaconess Medical Center and professor, Harvard Medical School, replies: A few of the statements Dr. Mensch made in his letter merit clarification and comment. First, the randomized trials that demonstrated the equivalence of lumpectomy and radiation therapy to mastectomy were not limited to patients with tumors less than 2 cm as he suggests; some included patients with tumors up to 4 or 5 cm.1-3 Second, I did not mean to suggest that a negative margin of “no tumor on ink” is an adequate margin in all patients undergoing lumpectomy. In fact, I clearly stated in the article that “we know from clinical follow-up studies that some patients need a wider margin.” The intent of my comments to CAP TODAY was to emphasize that there is currently no uniform agreement on what constitutes an adequate negative lumpectomy margin and that, as a result, too many patients undergo reexcision with its associated morbidity and cost. It is hoped that the multidisciplinary, evidence-based consensus conference on margins that will be held in 2013, and that was mentioned in my comments to CAP TODAY, will help to define more clearly which patients require a negative lumpectomy margin wider than “no tumor on ink” to reduce their risk of local recurrence and, conversely, in which patients a margin of “no tumor on ink” is adequate.

References

1. van Dongen JA, Voogd AC, Fentiman IS, et al. Long-term results of a randomized trial comparing breast-conserving therapy with mastectomy: European Organization for Research and Treatment of Cancer 10801 trial. J Natl Cancer Inst. 2000; 92:1143–1150.
2. Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 2002;347:1233–1241.
3. Poggi MM, Danforth DN, Sciuto LC, et al. Eighteen-year results in the treatment of early breast carcinoma with mastectomy versus breast conservation therapy: the National Cancer Institute Randomized Trial. Cancer. 2003;98:697–702.

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