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Invited Commentary |

Reoperation for Margins After Breast Conservation Surgery What’s Old Is New Again

Uttara Nag, MD1; E. Shelley Hwang, MD, MPH1
[+] Author Affiliations
1Department of Surgery, Duke University Medical Center, Durham, North Carolina
JAMA Surg. 2016;151(7):656. doi:10.1001/jamasurg.2015.5555.
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More than 30 years after demonstration that survival after breast conservation surgery (BCS) and adjuvant radiotherapy is equivalent to survival after mastectomy,1 significant variability in the implementation of BCS remains, particularly in the rates of reoperation for margins. Breast conservation surgery is the most common oncologic operation performed in the United States, with a measurable financial and physical burden caused by repeated excisions. In this issue of JAMA Surgery, the study by Isaacs et al2 reports a mean 90-day reoperation rate of 30.9% from 2003 to 2013 in New York State, with a significant decrease over time from 38.5% to 23.1%. This study shows that almost one-third of the reoperations results in mastectomy. In 2014, Wilke et al3 similarly demonstrated that within the National Cancer Database from 2004 to 2010, the rates of repeated operations after BCS decreased from 25% to 22%. This change is seen within the context of efforts to define adequate margins for BCS.4 The recent Society for Surgical Oncology–American Society for Radiation Oncology (SSO-ASTRO) consensus guidelines encourage the use of “no ink on tumor” as the current standard in an era of multimodal treatment and evolving understanding of tumor biology along with tumor burden. In fact, this approach to reexcisions echoes the conclusion of Fisher et al5(p1722) in 1986 after review of pathologic findings from the National Surgical Adjuvant Breast Project that “it is most appropriate to regard lines of resection involved only when cancer is transected,” because subjective designations of close margins resulted in second operations with a low yield of residual cancer.

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