If at first or second you don't succeed: mastectomy?

In this issue of Annals of Surgical Oncology, Menses et al. 1 reviewed factors associated with local recurrence after breast-conservation surgery in 459 patients treated for invasive and in situ carcinoma of the breast. Overall, the authors reported a local recurrence in 28 patients (6%) at 5 years. Nearly 50% of patients (n = 229) in this series had at least 1 reexcision, and only 22 patients had 2 or more reexcisions. The local recurrence rate in the 22 patients re-excised 2 or more times was 13.4%, compared with 5.6% of patients with 1 re-excision and 3.5% without a re-excision at 5 years. On multivariate analysis, the authors also found, in addition to the number of reexcisions, that age younger than 50 years and omission of radiotherapy were also independent factors associated with an increased local recurrence rate. The results of this study are intuitive to the surgical oncologist who routinely performs breast-conservation surgery. Many of us will continue to perform multiple attempts at breast conservation if removal of additional tissue is unlikely to cause a severe deformity and the patient has a very strong commitment to preserve her breast. This sometimes makes us feel uncomfortable because we are concerned that we may actually miss the specific margin that was found to be positive by the pathologist during the re-excision or that there may be a large amount of otherwise unidentified additional occult disease and because we are aware that the patients tumor size is an independent risk factor for obtaining positive margins during surgery. 2 Notwithstanding, in the absence of postmastectomy irradiation, it is important to be aware that larger invasive tumors are also associated with increased local recurrence rates in patients receiving mastectomy as the initial form of local therapy. 3 The answer to the question of what to do if we do not get negative margins on our first or subsequent attempted excision is simple: try, try again. If we had evidence that performing additional re-excisions adversely affected survival, then the answer would be different. So where do we go from here? With extensive intraoperative pathologic and radiographical processing, the rate of need for re-excision for margin control in patients receiving breast-conserving surgery at M. D. Anderson Cancer Center for ductal carcinoma-in-situ has been reduced to 22%. 4 It is not known whether the approximately 40% of patients who had re-excision at the initial operation for close or positive margins in the M. D. Anderson Cancer Center study 4 are at less risk for a local recurrence compared with patients who would have required a subsequent operation for re-excision. However, most patients would prefer one operation compared with two or more surgical procedures. Because the region of local recurrence in the breast is almost always at the area of initial excision, might patients requiring multiple re-excisions be candidates for an additional radiation boost at this site in an attempt to decrease local recurrence? 5 It is likely that better systemic therapies for both ductal carcinomain-situ and invasive breast cancer will further reduce rates of in-breast local recurrences. Accelerated partial breast irradiation using three-dimensional conformal radiation and brachytherapy is being tested in a randomized trial by the National Surgical Adjuvant Breast and Bowel Project and the Radiation Therapy Oncology Group. 5 Will more conformal radiation