1. There is no consensus on what constitutes an adequate margin during breast-conserving surgery, but most studies agree that tumor cells directly at the cut edge of the excised specimen is unacceptable. 2. While clear margins reduce the risk of local recurrence, they do not guarantee complete removal of the disease as 13-25% of cases with clear margins have residual tumor found on re-excision. 3. The risk of local recurrence increases with positive or close margins, and positive margins with invasive disease predict earlier recurrence compared to in situ disease. 4. The type of positive margin, such as multiple positive margins or extensive intraductal component, predicts a higher likelihood of residual tumor found on re-exc

1. WHAT IS AN ADEQUATE
MARGIN DURING BCS?
A surgeon’s view
Michel Daher, MD, FACS
President, Lebanese Cancer Society
Professor of Surgery- University of Balamand
Director, Ethics & Bioethics Teaching Program, UOB
Saint George Hospital- UMC, Beirut
3rd EASO Breast Reconstructive Workshop
Cairo, March 28, 2011

2. Germany
U.K.
Portugal
Antalya
Jordan
Saudi Arabia

3. Republic of Lebanon
 Population:
4.225.000
 Area: 10.452
Km2
 Specificity &
Diversity:
- Cultural
- Spiritual

4. Breast Cancer Incidence (ASR)

5. Breast Cancer in ME countries(1)
 Currently, breast cancer incidence
rates in ME are lower than in more
developed countries (4-5X lower
ASR than the U.S.)
 Screening is a challenge due to this
lower incidence (yield) and more
importantly, to inadequate
infrastructure for screening and
follow-up of what is found in a
screening program.
 A demographic shift toward older
populations is occurring that will
result in many more breast cancers U.S. ASR = 123.8
in the future.

6. Breast Cancer in ME countries (2)
 Late stage at diagnosis is
more common resulting in
higher mortality to
incidence ratios
 The contribution of biology
to poor outcomes warrants
more research.
 Palliative care services are
grossly inadequate
resulting in unnecessarily
painful end-of –life and
deaths .

7. Breast Cancer in ME countries (3)
Incidence Rates
There are no accurate data about neighboring
countries, but what is available shows that
Lebanon has the highest rate in the Middle
East.
Egypt (El Gharbiah) ASR: 49.6 (2002)
Jordan ASR: 21.3 (1997)
Algeria ASR: 9.5 (1997)
Kuwait ASR: 32.8 (1997)
Tunisia ASR: 16.7 (1994)
Lebanon ASR: 69.1 (2004)

8. Cancer in Lebanon
Annual New Cases* :
 2003- 7780 cases
 2004- 7450 cases
 2005- 8254 cases
 2006- 8230 cases
 2007- 8330 cases
 2008- 8250 cases
Death rate 6.39 per 1,000
Total deaths / year 24.092
- Cardio-V diseases 40%
- Cancers 13%
*Lebanese National Cancer Registry since 2003

9. Breast Cancer in Lebanon
 Most Common Cancer in women
worldwide
 InLebanon: More than One-third of all
women cancers are breast cancers
(Around 1420 cases a year)
 In most Arab Countries:
 More than 1/3 of all women cancers are
Breast Cancer
 More than ½ of patients are below age 50
years

10. Evolution In Surgical Techniques
Better knowledge of Natural History
Integration in Multidisciplinary Strategy
Adoption of Screening Campaigns

11. Objectives of Surgery
in Breast Cancer
 Confirm the Diagnosis ( most often
known before surgery)
 Define Prognostic Factors
 Achieve Loco-regional Control
 Preserve or Reconstruct the Breast

12. Surgical options in Primary BC
 Modified
radical Mastectomy +/-
Reconstruction
 Modifiedradical Mastectomy with
contralateral prophylactic Mastectomy
 Breast Conservative Surgery

13. Options between Modified Radical and
Conservative TT
Local Control
Survival
Quality of Life
Cosmetic Results
Ppsychological Acceptance
Follow up
Cost

14. Factors that may influence surgical option for
primary breast cancer
 Patient preference
 Pregnancy
 Multifocality (same quadrant)
 Response to Neo-Adjuvant Chemotherapy
 Tumor size in relation to breast size
 Retroareolar localisation
 Lobular Invasive Carcinoma
 Young Patient with Extensive Intraductal
Carcinoma

15. Contra-indications for Conservative
Treatment (1)
Modified Radical Mastectomy is mandatory
Tumor Multicentricity
Malignant Diffuse Microcalcifications
Failure of Neo-Adjuvant Chemotherapy
Previous Thoracic Irradiation
Resection Margins Positive for Tumor

16. Contra-indications for Conservative
Treatment (2)
Modified Radical Mastectomy is Mandatory
Inflammatory Carcinoma
Locally Advanced Carcinoma (skin infiltration)
Associated Diseases excluding Radiotherapy
(Sclerodermia, Tuberculosis)
Non Compliance for Post operative Surveillance

17. Final Decision for Surgical Option for
primary breast cancer
 Preop and Postop Radiology Study and may
include MRI
 Multidisciplinary concertation
 Optimal Surgery: Quality of Resection
(margin control), Esthetic Result
(Oncoplasty)
 Expertise of the Pathologist (Frozen Section,
Margin Control…)
 Final Pathology

18. Breast conserving surgery
140
120
100
80
60
40
20
0
1955 1958 1960 1964 1967 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001
-20 18

19. Conservative treatment of breast cancer
1
+ +/-
Breast conserving surg Radiotherapy Systemic treatment
2 + +
Systemic treatment Breast conserving surg Radiotherapy
+
Systemic treatment
19

20. Conservative Treatment of Breast Cancer
Excision of the Tumor together with at least 2
cm of tissue around the tumor + HP test of the
tumor and of the specimen margins
Quadrantectomy
In case of intra-ductal (in situ) component
Lumpectomy
High risk of residual microscopic disease
Frequent recurrence 20

21. The « Must » of a Conservative Treatment
Acceptable Local Control (<1% recurrence/year)
Acceptable Cosmetic Result (Shape, Volume,
Sensibility, Symetry) of Breast
Acceptable Morbidity ( due to axillary dissection)
Acceptaple Psychological Result
Veronesi U.; Changing concepts in breast cancer management, The European Journal of Cancer, vol. 34, Pergamon, sept. 1998, pg.3;
Development Panel Consensus National Institute of Health Consensus Statement; Treatment of early-stage breast cancer. J. Natl. Cancer Just Monogr. 1992; 11: 11 ;

22. Different Clinical Situations
Non Palpable Lesions
- Increase in frequency/ Screening
- Preop Diagnosis by Micro or Macro Biopsies
- Preoperative Localisation ( # méthods )
- Radiology Confirmation of the Oriented Specimen
Palpable Tumors
- Preop Diagnosis by FNA or FNB
-Allow a one-stage Good and Complete Excision
“The first excision is the best excision”

23. The Incisions
Depends of: the Localisation, Site, Size, Shape and
Breast Size
Different Types:
- Direct Incision:
- Peri-Areolar Incision:
Petit JY et al. Atlas of Breast Surgery (2008).
These Incisions must take into consideration the
possibility of a later mastectomy

24. Breast Excision/ Partial Mastectomy
-Quadrandectomy:
- Tumorectomy:

25. WHAT IS AN ADEQUATE MARGIN DURING
BCS?
Or what is a good
surgical resection?

26. WHAT IS AN ADEQUATE MARGIN DURING
BCS?
 In all studies with careful case definition,
the determination of clear margins has
been the most important feature predicting
the success of excision.
 However, overall size, some special
histologic patterns, and focal density of
disease near the margin have an effect in
some studies.

27. WHAT IS AN ADEQUATE MARGIN DURING
BCS?
• Need for close collaboration between
Surgeon, Pathologist, and Radiologist
• Specimen oriented, not opened, fresh,
and Inked
• Distance in mm between Tumor and
Margin
• Histology: Invasive or In Situ

28. Specimen Management
for the Pathologist
Orientation
Fresh
Closed
Inked

29. WHAT IS AN ADEQUATE MARGIN DURING
BCS?
 Definition of a Negative Margin
 Does Clear Margins= Complete Local
Control of the Disease?
 Is there a correlation between
Local Recurrence and Margins Status?
 Which type of Positive Margin Predict
Residual Tumor?
 What size of Negative Margins we Need?

30. WHAT IS AN ADEQUATE MARGIN DURING
BCS?
 Definition of a Negative Margin
 Does Clear Margins= Complete Local
Control of the Disease?
 Is there a correlation between
Local Recurrence and Margins Status?
 Which type of Positive Margin Predict
Residual Tumor?
 What size of Negative Margins we Need?

31. Definition of a Negative Margin:
controversies
• Margin microscopically négative( NSABP)
 • 1mm
 • 5mm
 • 1cm
 • More than 1cm ( Milano) ( Silverstein)

32. “ What is clear from the
preponderance of studies is that it is
absolutely unacceptable to have
tumor cells directly at the cut edge
of the excised specimen”
 S. Eva Singletary, MD, The American
Journal of Surgery, 2002

33. WHAT IS AN ADEQUATE MARGIN DURING
BCS?
 Definition of a Negative Margin
 Does Clear Margins= Complete Local
Control of the Disease?
 Is there a correlation between
Local Recurrence and Margins Status?
 Which type of Positive Margin Predict
Residual Tumor?
 What size of Negative Margins we Need?

34. Does Clear Margins= Complete Local
Control of the Disease?
 Review of cases with residual tumor
after Tumorectomy with Clear Margins *
 *13 - 25 % Residual Tumor
 And after systematic wider reexcision**
 **Total: 34/177 19,2 %

35. Does Clear Margins= Complete Local
Control of the Disease?
Author (Year) Nb with residual T (margin < 0)
 Smitt (95) 2/8 25 %
 Beron (96) 5/38 13 %
 Saarela (97) 4/26 15 %
 Beck (98) 23/105 22 %

36. Peritumoral
microscopic disease
17%
42%
59%
1 1 1
T1 cm cm cm
36

37. Does Clear Margins= Complete Local
Control of the Disease?
 Clear Margins does not guarantee for a complete
excision of the disease
 This can explain the Recurrence Rate at 10 years
after quadrantectomy:
Without RadioT 27,1 %
With RadioT 6,9 %
 The risk for residual disease is minimal but not nil
for clear margins
 What size of Neg Margins we need ?

38. WHAT IS AN ADEQUATE MARGIN DURING
BCS?
 Definitionof a Negative Margin
 Does Clear Margins= Complete Local
Control of the Disease?
 Is there a correlation between
Local Recurrence and Margins Status?
 Which type of Positive Margin Predict
Residual Tumor?
 What size of Negative Margins we Need?

39. Is there a correlation between
Local Recurrence and Margins Status?
 Negative Margins: 2-12%
 “Close” Margins (less than1mm): 6-13%
 Focally Positive Margins: ~14%
 Multiple Focally Pos Margins: 15-27%
J Am Coll Surg 2007;205: 362–376.

40. Is there a correlation between
Local Recurrence and Margins Status?
 Positive Margin does not mean obligatory
résidual tumor*
 Local Recurrence increases if Positive Margins*
 8 - 25 % follow up 3,5 à 4,5 y (8-13-13-18-25)
 6 - 24 % follow up 5 - 8 y (6-10-10-10-11-15-16-17- 19-20-22-
24)
 12 - 31 % follow up 10 y (12-15-16-31)
 Local Recurrence is earlier in positive margins
with Invasive v/s In Situ**
 20 % at follow up 5 y
 29 % at follow up 10 y
*(Horiguchi 99, Gage 96, Dibiase 98, Peterson 99)
**(D Cowen, G Houvenaeghel, V Bardou et al IJROBP 2000)

41. WHAT IS AN ADEQUATE MARGIN DURING
BCS?
 Definition of a Negative Margin
 Does Clear Margins= Complete Local
Control of the Disease?
 Is there a correlation between
Local Recurrence and Margins Status?
 Which type of Positive Margin Predict
Residual Tumor?
 What size of Negative Margins we Need?

42. Which type of Positive Margin Predict
Residual Tumor?
Review of Residual Tumor in Reexcision Specimen
 Author (year) Nb cases + margin No residual T
 Haga 1995 7/23 30 %
 Beron 1996 29/41 71 %
 Wazer 1997 71/160 44 %
 Saarela 1997 5/8 62 %
 Beck 1998 16/39 41 %
 Papa 1999 67/115 58 %
 Résidual T.: 29 à 70 % 191 / 386 49,5 %

43. Which type of Positive Margin Predict
Residual Tumor?
 Author (year) + margin margin < 0
 Wazer 1997 89/160 56 % 22/61 36 %
 Beron 1996 12/41 29 % 13 %
 Predictive Factors for residual T.:
 + margin and Nb of + margins
 Présence of extensive intraductal component (Wazer)

44. Van Nuys Prognostic Index in DCIS
Score 1 2 3
Size =< 15 mm >15-40 mm >40 mm
Margins >=10 mm 1-10 mm <1 mm
Grade Low Grade Low Grade High Grade
No nécrosis Nécrosis Nécrosis

45. Van Nuys Prognostic Index in DCIS
Final Score Recurrence Survival (8y)
 3-4 3,8% 93%
 5-7 11,1% 84%
 8-9 26,5% 61%

46. WHAT IS AN ADEQUATE MARGIN DURING
BCS?
 Definition of a Negative Margin
 Does Clear Margins= Complete Local
Control of the Disease?
 Is there a correlation between
Local Recurrence and Margins Status?
 Which type of Positive Margin Predict
Residual Tumor?
 What size of Negative Margins we Need?

47. What size of Negative Margins we
Need?
Local Recurrence with > 1 mm free Margin
 Author Nb marge >1 marge <1 marge + Follow up
 Recht 134 3 11 22 5y
 Borger 723 2 6 16 5
 Park 486 7 7 19 8
2-7% 6-11%

48. What size of Negative Margins we
Need?

Local Recurrence with > 2<2mm free Margin
Author Nb margin >2mm margin
mm Followup
 Dewar 663 6 14 10
 Kini 400 6 - 10
 Smitt 303 2 24 10
 Freedman 1262 7 14 10
 Wazer 494 4 14 12

49. What size of Negative Margins we Need?
Local Recurrence with > 5 mm free Margin
Margins + 0-2 2-5 > 5
Local Rec 17% 9% 5% 0% p: 0,009
Factors for Local Rec.: age < 45,
marge < 2mm
Neuschatz et al Cancer 2003 - 509 pts, follow up 10y

50. Local Recurrence and Adjuvant Chemotherapy
margin - margin + <1
Follow up 5y 10y 5y 10y
% LR
ChemoT 3 7 1 12
No ChemoT 5 7 11 16
(p = 0,02)
Margin + ou <1: after ChemoT most of Local Recurrences
appears between 5 and 10 y
G. Freedman et al IJROBP 1999

51. Need for Reexcision- When ?
 Neg Margins : NO
 “Close” margins= (>= than 2mm): Optional
 Focally Pos Margins: Yes
 Pos Margins or Multiple Focally+ :YES
Positive Margin

52. Need for Reexcision- How?
 Use same incision (rarely have to enlarge)
 Prior orientation allows select resection
 Resect 0.5- 1.0 cm tissue for entire new
margin
 Orient new margin with stitch placed at
Positive Margin
new margin
 Meticulous hemostasis

53. Conclusions (1)
 Conservative treatment of breast cancer involves Team Work.
The results depend on the team members expertise and
competence.
 “The first excision is the best excision”
 Specimen oriented, not opened, fresh, and Inked
 Definition of a Negative Margin: controversies
 Clear margins has been the most important feature predicting
the success of excision
 There is a correlation between Local Recurrence, Overall
Survival and Margins Status

54. Conclusions (2)
 Risk factors associated with higher local recurrences:
+ margins, < 40y patients, no adjuvant RadioT
 Recommendation for Reexcision with acceptable
cosmetic result or Mastectomy if + Margins or Close
Margin (less than 2 mm)
 Discuss alternatives: Boost RadioT
 Good Information to the patient: local recurrence,
survival, therapeutic alternatives
 Experience, Volume, and Multidisciplinarity approach

55. Not to See This..

56. But This..

57. Breast Cancer Awareness
Campaigns Lebanon

58. Breast Cancer Awareness
Campaigns Lebanon 2010
2010

60. UPDATES ON CANCER PAIN & PALLIATIVE
CARE
Middle East Medical Assembly (MEMA)
In Collaboration with
Lebanese Cancer Society (LCS)
Rafic Hariri School of Nursing HSON)
Lebanese Society for the Study of Pain (LSSP)
Friday May 6, 2011
Beirut, Lebanon
All Are Welcome