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What is the optimal margin ? “Relevant for radiation therapy”

What is the optimal margin ? “Relevant for radiation therapy”

What is the optimal margin ?

“Relevant for radiation therapy”

รศ.นพ.ประเสริฐ เลิศสงวนสินชัย

โรงพยาบาลวัฒโนสถ


                    The treatment of breast cancer require multidisciplinary approach.  Previously, the standard surgical management for a patient with breast cancer is mastectomy.   Since 1980, the new standard in the treatment of non-invasive (ductal carcinoma in situ, DCIS) and early stage invasive breast cancer are breast conserving therapy which composed of local excision (lumpectomy) with clear surgical margins and good or acceptable cosmetic result then follow by postoperative radiation therapy.

 

                    There are four large randomized control trials for patients with Ductal Carcinoma In Situ (NSABP B-17, EORTC 10853, NSABP B-24 and The UK trial) showed that lumpectomy and breast irradiation 50 Gy/25F/5 weeks have a statistically significant improve in local control as compare to lumpectomy alone when follow up to 5 and 8 years.   However, there have no different in overall survival.   The studies showed that tumor size, pathological characteristics, patient age and free surgical margins width are the prognostic parameters for local recurrence.   Patients who have less than 2 mm free surgical margins width and underwent re-excision or mastectomy specimens demonstrated high positive residual carcinoma.   Patients who have 1 cm or more free surgical margins width with low prognostic risk group have low probability of local recurrence and may be no need or no benefit for postoperative radiation therapy.

  

                   For patients with early stage invasive breast cancer, there are several large randomized control trials with long-term follow up (NSABP B-06, Scottish Cancer Trial, Uppsala-Orebro, Ontario, Milan-3, EORTC Trial, Lyon France Trial, etc) showed no different in locoregional recurrence and overall survival in patients treated with lumpectomy and breast irradiation with or without tumor bed boost 10-20 Gy as compare to patients who treated with mastectomy.   However, there is significant decrease in locoregional recurrence in patients treated with lumpectomy and breast irradiation as compare to patients treated with lumpectomy alone.   The free surgical margins is the most important prognostic factor for locoregional recurrence.   The pathological evaluation of re-excision or mastectomy specimens in patients whose initial excision of the primary tumor with a 1-2 mm free surgical margins width revealed 15-17% residual carcinoma.   So, for early stage I-II breast cancer a lumpectomy with a 1-2 mm microscopic free surgical margins width is appropriate for breast conserving therapy.
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