Overall survival in patients with a re-excision following breast conserving surgery compared to those without in a large population-based cohort

Published:December 27, 2014DOI:



      To investigate the overall survival of invasive breast cancer patients with primary breast conserving surgery (BCS) followed by re-excision compared to those with primary BCS only. The Dutch re-excision indications are less stringent compared to other European and Northern American countries (Society of Surgical Oncology-American Society for Radiation Oncology (SSO/ASTRO) guideline).


      Retrospective analyses in women <75 years with breast cancer stage pT1–T3 treated by BCS and radiotherapy between 1999 and 2012 from a population-based database. The national guideline recommends to reserve re-excision for invasive tumours showing ‘more than focally positive’ margin since 2002. Patients were divided into ‘primary BCS only’, ‘re-excision by BCS’, and ‘re-excision by mastectomy’. Multivariable Cox regression analysis was adjusted for patient and systemic treatment characteristics.


      A total of 11,695 patients were included of which 2156 (18.4%) underwent re-excision. Median time of follow-up was 61 months (interquartile range (IQR) 26–101). The 5-year overall survival rates in the ‘primary BCS only’, ‘re-excision by BCS’ and ‘re-excision by mastectomy’ group were 92%, 95% and 91%, respectively. The 10-year overall survival rates were 81%, 82% and 79%, respectively (P = 0.20). After multivariable analyses no significant association was observed between use of and type of re-excision and overall survival.


      The overall survival of breast cancer patients with a re-excision did not significantly differ from the survival of women who underwent primary BCS only. Advising re-excision only for those tumours showing ‘more than focally positive’ resection margin appears safe, supposing the long-term safety of the recent SSO/ASTRO guideline that more cautiously recommended re-excision for tumours showing ‘ink on tumour’.


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        • Litiere S.
        • Werutsky G.
        • Fentiman I.S.
        • Rutgers E.
        • Christiaens M.R.
        • Van Limbergen E.
        • et al.
        Breast conserving therapy versus mastectomy for stage I–II breast cancer: 20 year follow-up of the EORTC 10801 phase 3 randomised trial.
        Lancet Oncol. 2012; 13: 412-419
        • Veronesi U.
        • Cascinelli N.
        • Mariani L.
        • Greco M.
        • Saccozzi R.
        • Luini A.
        • 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
        • Fisher B.
        • Anderson S.
        • Bryant J.
        • Margolese R.G.
        • Deutsch M.
        • Fisher E.R.
        • 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
        • Park C.C.
        • Mitsumori M.
        • Nixon A.
        • Recht A.
        • Connolly J.
        • Gelman R.
        • et al.
        Outcome at 8 years after breast-conserving surgery and radiation therapy for invasive breast cancer: influence of margin status and systemic therapy on local recurrence.
        J Clin Oncol. 2000; 18: 1668-1675
        • Kreike B.
        • Hart A.A.
        • van de Velde T.
        • Borger J.
        • Peterse H.
        • Rutgers E.
        • et al.
        Continuing risk of ipsilateral breast relapse after breast-conserving therapy at long-term follow-up.
        Int J Radiat Oncol Biol Phys. 2008; 71: 1014-1021
        • Meric F.
        • Mirza N.Q.
        • Vlastos G.
        • Buchholz T.A.
        • Kuerer H.M.
        • Babiera G.V.
        • et al.
        Positive surgical margins and ipsilateral breast tumor recurrence predict disease-specific survival after breast-conserving therapy.
        Cancer. 2003; 97: 926-933
        • Voogd A.C.
        • Nielsen M.
        • Peterse J.L.
        • Blichert-Toft M.
        • Bartelink H.
        • Overgaard M.
        • et al.
        Differences in risk factors for local and distant recurrence after breast-conserving therapy or mastectomy for stage I and II breast cancer: pooled results of two large European randomized trials.
        J Clin Oncol. 2001; 19: 1688-1697
        • Houssami N.
        • Macaskill P.
        • Marinovich M.L.
        • Dixon J.M.
        • Irwig L.
        • Brennan M.E.
        • et al.
        Meta-analysis of the impact of surgical margins on local recurrence in women with early-stage invasive breast cancer treated with breast-conserving therapy.
        Eur J Cancer. 2010; 46: 3219-3232
        • Morrow M.
        • Harris J.R.
        • Schnitt S.J.
        Surgical margins in lumpectomy for breast cancer—bigger is not better.
        N Engl J Med. 2012; 367: 79-82
        • Moran M.S.
        • Schnitt S.J.
        • Giuliano A.E.
        • Harris J.R.
        • Khan S.A.
        • 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 stages I and II invasive breast cancer.
        Ann Surg Oncol. 2014; 21: 704-716
        • Azu M.
        • Abrahamse P.
        • Katz S.J.
        • Jagsi R.
        • Morrow M.
        What is an adequate margin for breast-conserving surgery? Surgeon attitudes and correlates.
        Ann Surg Oncol. 2010; 17: 558-563
        • Moran M.S.
        • Schnitt S.J.
        • Giuliano A.E.
        • Harris J.R.
        • Khan S.A.
        • 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 stages I and II invasive breast cancer.
        J Clin Oncol. 2014; 32: 1507-1515
        • van de Water W.
        • Bastiaannet E.
        • Dekkers O.M.
        • de Craen A.J.
        • Westendorp R.G.
        • Voogd A.C.
        • et al.
        Adherence to treatment guidelines and survival in patients with early-stage breast cancer by age at diagnosis.
        Br J Surg. 2012; 99: 813-820
        • Taghian A.
        • Mohiuddin M.
        • Jagsi R.
        • Goldberg S.
        • Ceilley E.
        • Powell S.
        Current perceptions regarding surgical margin status after breast-conserving therapy: results of a survey.
        Ann Surg. 2005; 241: 629-639
      1. NABON. Breast cancer guideline; 2002. <>.

        • Fisher B.
        • Jeong J.H.
        • Anderson S.
        • Wolmark N.
        Treatment of axillary lymph node-negative, estrogen receptor-negative breast cancer: updated findings from National Surgical Adjuvant Breast and Bowel Project clinical trials.
        J Natl Cancer Inst. 2004; 96: 1823-1831
        • Schouten L.J.
        • Hoppener P.
        • van den Brandt P.A.
        • Knottnerus J.A.
        • Jager J.J.
        Completeness of cancer registration in Limburg, The Netherlands.
        Int J Epidemiol. 1993; 22: 369-376
        • Early Breast Cancer Trialists’ Collaborative G.
        Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials.
        Lancet. 2005; 365: 1687-1717
        • Nowak A.K.
        • Wilcken N.R.
        • Stockler M.R.
        • Hamilton A.
        • Ghersi D.
        Systematic review of taxane-containing versus non-taxane-containing regimens for adjuvant and neoadjuvant treatment of early breast cancer.
        Lancet Oncol. 2004; 5: 372-380
        • Romond E.H.
        • Perez E.A.
        • Bryant J.
        • Suman V.J.
        • Geyer Jr., C.E.
        • Davidson N.E.
        • et al.
        Trastuzumab plus adjuvant chemotherapy for operable HER2-positive breast cancer.
        N Engl J Med. 2005; 353: 1673-1684
        • Piccart-Gebhart M.J.
        • Procter M.
        • Leyland-Jones B.
        • Goldhirsch A.
        • Untch M.
        • Smith I.
        • et al.
        Trastuzumab after adjuvant chemotherapy in HER2-positive breast cancer.
        N Engl J Med. 2005; 353: 1659-1672
        • Singletary S.E.
        Surgical margins in patients with early-stage breast cancer treated with breast conservation therapy.
        Am J Surg. 2002; 184: 383-393
        • Vordermark D.
        • Lackenbauer A.
        • Wulf J.
        • Guckenberger M.
        • Flentje M.
        Local control in 118 consecutive high-risk breast cancer patients treated with breast-conserving therapy.
        Oncol Rep. 2007; 18: 1335-1339
        • O’Sullivan M.J.
        • Li T.
        • Freedman G.
        • Morrow M.
        The effect of multiple reexcisions on the risk of local recurrence after breast conserving surgery.
        Ann Surg Oncol. 2007; 14: 3133-3140
        • Aziz D.
        • Rawlinson E.
        • Narod S.A.
        • Sun P.
        • Lickley H.L.
        • McCready D.R.
        • et al.
        The role of reexcision for positive margins in optimizing local disease control after breast-conserving surgery for cancer.
        Breast J. 2006; 12: 331-337
        • Menes T.S.
        • Tartter P.I.
        • Bleiweiss I.
        • Godbold J.H.
        • Estabrook A.
        • Smith S.R.
        The consequence of multiple re-excisions to obtain clear lumpectomy margins in breast cancer patients.
        Ann Surg Oncol. 2005; 12: 881-885
        • Vrieling C.
        • Collette L.
        • Fourquet A.
        • Hoogenraad W.J.
        • Horiot J.C.
        • Jager J.J.
        • et al.
        Can patient-, treatment- and pathology-related characteristics explain the high local recurrence rate following breast-conserving therapy in young patients?.
        Eur J Cancer. 2003; 39: 932-944
        • Vapiwala N.
        • Harris E.
        • Hwang W.T.
        • Solin L.J.
        Long-term outcome for mammographically detected ductal carcinoma in situ managed with breast conservation treatment: prognostic significance of reexcision.
        Cancer J. 2006; 12: 25-32
        • Adams B.J.
        • Zoon C.K.
        • Stevenson C.
        • Chitnavis P.
        • Wolfe L.
        • Bear H.D.
        The role of margin status and reexcision in local recurrence following breast conservation surgery.
        Ann Surg Oncol. 2013; 20: 2250-2255
        • Ali A.N.
        • Vapiwala N.
        • Guo M.
        • Hwang W.T.
        • Harris E.E.
        • Solin L.J.
        The impact of re-excision and residual disease on local recurrence after breast conservation treatment for patients with early stage breast cancer.
        Clin Breast Cancer. 2011; 11: 400-405
        • Kouzminova N.B.
        • Aggarwal S.
        • Aggarwal A.
        • Allo M.D.
        • Lin A.Y.
        Impact of initial surgical margins and residual cancer upon re-excision on outcome of patients with localized breast cancer.
        Am J Surg. 2009; 198: 771-780
        • Tartter P.I.
        • Kaplan J.
        • Bleiweiss I.
        • Gajdos C.
        • Kong A.
        • Ahmed S.
        • et al.
        Lumpectomy margins, reexcision, and local recurrence of breast cancer.
        Am J Surg. 2000; 179: 81-85