Breast  Joint  clinic ( Tumor board)        April 9, 2016

Case presentation: ( Margin status in BCS )

31 yrs female, FH positive (her aunt), Premenopause, Known case of Lt breast cancer operated 7 months ago in other hospital , Breast conserving surgery & ALND ( september 2015 ), Carcinosarcoma*, size 3 cm, PNI + , LVI +, ER - , PR - , Her2 - , Ki67 40%, Lateral margin very close , LN 5/7 + , Adjuvant treatment: Chemotherapy 8 course

PMH: Rt ovary endodermal sinus tumor(10 years ego), Rt oophorectomy            -10 course chemotherapy

CC: Feeling of Lt breast mass scar

PE: Palpable tickening under scar (incision) of BCS

US: Lt hetero-echoic mass 32*26 mm at 2 O’C ( B 4 )

MG: Lt focal asymmetry at anterior part ( B 4b )

Mets workup: Negative

Question: Need to re-excision (for safe margin) or Mastectomy before XRT ?

Joint recommendation:

CNBx & pathologic evaluation of mass.

(Positive malignancy : Mastectomy & XRT),
(Negative malignancy : Observation & XRT)

Reference:                                                           

1-Jay R Harris,Monica Moro.”Diseases of the breast”. 5th ed. ,2014

Page 894: IBTRs( Ipsilateral breast tumor recurrence) occurring in previously radiated BCT patients are often treated with mastectomy, which is generally felt to be the standard management approach. For patients who have not been treated with radiation therapy as a component of their initial treatment,a repeat breast conservation procedure with excision of the recurrence followed by a course of radiation therapy can be considered. The rates of recurrence are greater after a second local excision compared with mastectomy.

In carefully selected patients with mobile tumors measuring less than 2 cm in size and favorable pathologic features, 5-year local control approaches nearly 80%, and is significantly better for patients in whom a negative margin was attained on the second local excision surgery. A second local excision without additional radiation therapy, local relapse rates range from approximately 20%to 50%.

Page 515: A negative margin is defined by “no ink on any cancer cells.”Many practitioners favor a margin of 2 mm or even greater. As a result, re-excision is commonly used, even with a negative margin. A meta-analysis of 21 studies reporting LR relative to margin width showed that LR was significantly greater with a positive margin than a negative margin, but increasing margin width did not significantly decrease LR.

2-NCCN guideline  2016

 Page 39 : The NCCN panel accepts the definition of a negative margin as “No ink on tumor”. Cases where

 there is positive margin should generally undergo further surgery, either a re-excision to achieve a negative

 margin or a mastectomy. It may be reasonable to treat selected cases with breast-conserving therapy with a

 microscopically focally positive margin in the absence of EIC with use of higher radiatin boost dose to the tumor bed.

 *:  Carcinosarcoma of the breast, often referred to as metaplastic carcinoma of the breast, is a rare malignancy with very few cases reported in the literature. 

 




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