Clear margins for invasive lobular carcinoma: A surgical challenge

https://doi.org/10.1016/j.ejso.2011.01.010Get rights and content

Abstract

Background

The main goal of breast conservative surgery (BCS) is the complete removal of cancer with clear margins and no deformity of the breast. However, in invasive lobular carcinoma (ILC) this goal is hard to achieve because of the underestimation of tumor size. Our study was the first to show the role of surgical techniques in the achievement of clear margins for ILC.

Methods

We reviewed 73 patients with ILC who underwent BCS at Paris Breast Center between January 2005 and June 2008. Full thickness excision (FTE) was performed in a routine basis and oncoplastic surgery (OPS) upon tumor location, volume ratio and overall density of the breast. Margin status was evaluated as positive, close or clear.

Results

Positive/close margins were found in 39% of cases and were lower than what was described in the literature (49–63%). FTE was performed in 47 (64%) patients and OPS in 26 (36%) patients. No positive/close margins were observed in patients with lesions located in the lower/central quadrants. Multivariate analysis showed multifocality, larger tumor size and FTE to be independent risk factors for positive margins at final surgery.

Conclusions

Our rate of positive/close margins for ILC was lower than what was described in the literature. The determinant key difference was in our surgical procedures with FTE or OPS differing from the standard BCS described in the literature and we suggest that OPS is to be considered for ILC. It allows larger breast conservative surgery with good cosmetic results and lower rate of compromised margins.

Introduction

The main goal of breast conservative surgery (BCS) is the complete removal of cancer with clear surgical margins while maintaining the natural shape of the breast. In BCS for invasive lobular carcinoma (ILC) the primary goal of complete cancer removal with adequate surgical margins is hard to achieve compared to BCS for invasive ductal carcinoma (IDC). Historically, ILC accounts for 10% of invasive breast cancers and patients undergoing BCS for ILC frequently have higher rates of involved margins often in excess of 50%.1, 2 Therefore the challenge in obtaining negative margins is partly due to the underestimation of tumor size with standard imaging modalities during preoperative surgical planning. This underestimation of size by both mammography or ultrasound evaluation is known to be mainly due to the lack of a desmoplastic reaction for ILC and preoperative assessment with magnetic resonance imaging (MRI) have shown improvement in size estimation.3, 4, 5

Series has demonstrated the difficulty to achieve negative margins after BCS for ILC and a reliable surgical solution regarding the limited success of BCS for ILC has not been developed.1, 6, 7 Few reports were extensively exploring intra-operative strategies for reducing rates of re-excision in both invasive ductal carcinoma (IDC) and ductal carcinoma in situ (DCIS) but similar studies for patients with ILC are limited in scope.8 More recently, reports have shown that oncoplastic surgery (OPS) was effective in reducing re-excision rate for positive margins in IDC and DCIS.9, 10 OPS is defined by the combination of surgical oncology principles with plastic surgery techniques allowing larger excision of breast tissue compared to standard BCS.11 It has resulted in the successful treatment of patients with DCIS and IDC, and our study is the first to evaluate the effectiveness of surgical techniques including OPS in ILC.

We reviewed patients with ILC undergoing BCS at Paris Breast Center and found a lower rate of involved margins (39%) compared to previous studies.1, 6, 7 Our aim was to explore the role of surgical techniques in the achievement of clear margins for ILC.

Section snippets

Patient selection

Seventy-three patients with ILC who underwent BCS at Paris Breast Center between 2005 and 2008 were included in the study with the approval of the center institutional committee. Selection criteria for conservative treatment included T1–T2 breast cancer as well as patient desire of breast conservation. Contraindications to BCS were multicentricity, recurrence or prior chest radiotherapy and neoadjuvant chemotherapy. In addition to preoperative clinical and mammographic evaluation, all patients

Results

A total of 73 patients with ILC treated with BCS were included in the study. The median patient age was 58 years (range 37–76 years). Margins were clear in 44 cases, close in 10 cases and positive in 19 cases. A second re-excision was performed in 17 patients with positive/close margins: 12 patients had mastectomy and residual carcinoma was found in 9 patients.

Alternative surgery for ILC

Through differing surgical techniques, BCS can be safely considered for ILC in spite of earlier concerns and failures. Studies that addressed BCS in ILC were either suggesting that it was a good alternative for mastectomy or expressing reservation regarding the lack of surrounding desmoplastic reaction.12, 13, 14, 15 Although there have been studies with long follow-up after BCS reporting similar outcome in terms of local recurrence and survival for ILC as for IDC, this is the first study that

Conclusion

Obtaining clear margins could be difficult with ILC since resection of large and unlimited tumors needed more consideration and planning in order to remove the malignant tissue with adequate margins and good cosmetic result. While the management of ILC regarding breast conservation remains difficult because of the higher rate of involved margins and re-excision, our study revealed a lower rate of positive/close margins for ILC tumors than what was already described. Our surgical procedure with

Acknowledgments

We would like to thank Pr Roman Rouzier for his assistance with the statistical analysis.

References (25)

  • M.J. Silverstein et al.

    Infiltrating lobular carcinoma. Is it different from infiltrating duct carcinoma?

    Cancer

    (1994)
  • M.M. Moore et al.

    Association of infiltrating lobular carcinoma with positive surgical margins after breast-conservation therapy

    Ann Surg

    (2000)
  • Cited by (28)

    • Intraoperative radiation therapy in early-stage breast cancer: Presence of lobular features is not associated with increased rate of requiring additional therapy

      2020, American Journal of Surgery
      Citation Excerpt :

      The increased risk of ischemic heart disease and radiation-associated malignancies as well as the challenges associated with a prolonged course of daily WBRT may also drive some patients’ decision to pursue mastectomy despite being appropriate candidates for BCT.20,21 With its unpredictable and infiltrative growth pattern, lobular histology has been associated with an increased rate of inadequate margins.22–25 The concern for inability to achieve clear margins in a single excision has played a role in the limited study of IORT in patients with LF.

    • Therapeutic mammoplasty allows for clear surgical margins in large and multifocal tumours without delaying adjuvant therapy

      2015, Breast
      Citation Excerpt :

      Our data also demonstrates the ability of TM to achieve widely clear surgical margins well in excess of those that might be achieved by conventional BCS techniques in tumours of any size. This supports studies that have reported the successful use of TM in obtaining clear surgical margins in tumours up to 100 mm [14–16]. Where positive margins did occur in this study (3/68), two were due to ductal carcinoma in situ (DCIS) and one from an invasive lobular cancer significantly larger than predicted by pre-operative imaging.

    • Quality of information reporting in studies of standard and oncoplastic breast-conserving surgery

      2014, Breast
      Citation Excerpt :

      16 studies met the inclusion criteria for sBCS (n = 11,767 patients), all reporting level 1 evidence (Tables 2, 4 and 5) [8–23]. 53 studies met the inclusion criteria for oBCS (n = 3236 patients), none of which were RCTs, including 11 studies reporting level 2 evidence, 33 studies level 3, and 9 studies level 4 evidence (Tables 3–5) [24–76]. 41 studies reported volume displacement techniques, 9 studies volume replacement techniques, and 3 studies both techniques.

    • Two-year quality of life after breast cancer surgery: A comparison of three surgical procedures

      2011, European Journal of Surgical Oncology
      Citation Excerpt :

      Sexual dysfunction in breast cancer patients may result from premature menopause after adjuvant systemic therapy.25 In the current study, patients with a short follow-up intervals reported better physical and mental functioning whereas patients with a long intervals tended to have satisfactory body image, which is in line with other studies.2,20 One explanation for these observations is the use of coping mechanisms by patients to deal with the stress caused by adverse diagnoses and the potentially life-threatening effects of primary therapy.

    View all citing articles on Scopus
    View full text