Overview
Definition:
Margin re-excision in breast conservation surgery refers to the secondary surgical procedure performed after an initial breast-conserving lumpectomy to achieve negative surgical margins when the initial excision resulted in tumor cells at the inked margin
The goal is to remove any residual microscopic or macroscopic tumor to reduce the risk of local recurrence.
Epidemiology:
The incidence of positive margins after initial lumpectomy varies widely, reported between 10% and 40% in different studies, influenced by tumor characteristics, surgical technique, and margin assessment methods
Re-excision rates also vary but are significant enough to be a critical consideration in breast cancer management.
Clinical Significance:
Achieving negative margins is a cornerstone of successful breast conservation surgery
Positive margins are associated with a significantly increased risk of local breast cancer recurrence, impacting patient survival and the need for subsequent therapies
Optimizing margin status is crucial for oncologic control and patient satisfaction with breast preservation.
Indications For Re Excision
Definition:
Re-excision is indicated when the initial surgical specimen reveals tumor at the inked margin, or within a specified distance deemed inadequate by guidelines
This also includes cases where residual tumor is identified on subsequent imaging or pathology review after the initial surgery.
Pathological Criteria:
Pathology reports indicating tumor cells at any inked margin (close margin <1-2mm or positive margin) are the primary indication
The definition of a "close" margin can vary slightly based on institutional protocols and specific tumor types, but generally, anything within 2 mm warrants consideration for re-excision or adjuvant radiation techniques.
Radiological Findings:
Occasionally, residual disease may be suspected on post-operative imaging if there is persistent enhancement or suspicious findings in the lumpectomy bed that were not fully excised initially, though this is less common than pathological confirmation.
Preoperative Preparation
Pathology Review:
Thorough review of the initial pathology report by the surgeon and pathologist is essential
Confirmation of positive or close margins and the exact location of the residual tumor guides the re-excision plan.
Imaging Review:
Review of preoperative mammography, ultrasound, and MRI can help delineate the extent of the original tumor and identify any residual areas that might have been missed or remain.
Patient Counseling:
Discussing the need for re-excision, its potential benefits (reducing recurrence risk), and risks (additional surgery, potential cosmetic compromise, increased recovery time) with the patient is vital
Understanding patient preferences and expectations is important.
Surgical Management Re Excision
Technique Selection:
Re-excision can be performed via re-lumpectomy, mastectomy, or sometimes using minimally invasive techniques like image-guided biopsy or vacuum-assisted excision if the residual lesion is small and well-defined
Re-lumpectomy involves identifying the original tumor bed and excising an additional margin of tissue.
Intraoperative Guidance:
Techniques like specimen radiography, intraoperative ultrasound, tattooing of margins, or specimen orientation by the surgeon/pathologist are used to ensure adequate tissue removal and proper margin assessment during the re-excision procedure.
Margin Assessment:
The re-excised specimen must be carefully oriented and sent for pathological examination to confirm negative margins
Frozen section analysis may be considered in select cases, although its routine use for margin assessment in re-excision is debated.
Postoperative Care And Follow Up
Wound Care:
Standard postoperative wound care, including pain management, infection prevention, and monitoring for hematoma or seroma formation
Increased risk of wound complications may exist after re-excision.
Pathology Results:
Detailed review of the final pathology report from the re-excision specimen is critical to confirm achieving negative margins
If margins remain positive, further treatment options such as completion mastectomy or re-re-excision may be considered.
Long Term Monitoring:
Patients with re-excised margins still require regular follow-up with clinical breast exams and surveillance imaging as per standard breast cancer guidelines to monitor for local recurrence and contralateral disease.
Complications
Early Complications:
Wound dehiscence
Seroma formation
Hematoma
Infection
Pain
Increased risk of cosmetic deformity compared to initial lumpectomy.
Late Complications:
Fibrosis and scarring of the breast tissue
Distortion of breast shape or symmetry
Potential impact on breast reconstruction options if a mastectomy is subsequently required.
Prevention Strategies:
Meticulous surgical technique, appropriate wound closure, drain management, and patient selection for re-excision
Clear communication between surgeon and pathologist is paramount
Considering adjuvant radiation techniques for close margins when re-excision is not feasible or preferred.
Key Points
Exam Focus:
The primary goal of margin re-excision is to reduce the risk of local breast cancer recurrence
Positive or close margins (<1-2 mm) on initial lumpectomy specimen are the main indications
Careful specimen orientation and communication with pathology are crucial.
Clinical Pearls:
When faced with a close margin, weigh the benefit of re-excision against potential cosmetic compromise and patient preference
Always involve the pathologist early in the decision-making process
Consider intraoperative margin assessment techniques if available.
Common Mistakes:
Inadequate re-excision leading to persistent positive margins
Failure to properly orient the specimen for pathology
Poor communication between the surgical and pathology teams
Undertreating close margins without considering adjuvant therapies or further surgery.