Today I read in the news that author Jane Fallon, partner to actor and comedian Ricky Gervais, was sadly recently diagnosed with breast cancer. She has shared that her surgeon had 'got it all' after the first surgery but did not get clear margins around the tumour, so she needs to have another op. This …
Today I read in the news that author Jane Fallon, partner to actor and comedian Ricky Gervais, was sadly recently diagnosed with breast cancer. She has shared that her surgeon had ‘got it all’ after the first surgery but did not get clear margins around the tumour, so she needs to have another op. This news made me want to write a little about margins in breast cancer surgery.
When we perform breast conserving surgery (aka lumpectomy), we are required in the UK to have at least 1 mm (in the USA and many parts of the world ‘no tumour on ink’) of clear margins from the edge of the tumour under the microscope when the specimen is examined for invasive tumours, and 2 mm for pure pre-invasive tumours (DCIS, also commonly misnomered precancerous). This has shown to provide the lowest rate of local recurrence and is based on all available evidence and recommended by Association of Breast Surgery, and NICE.
However, margins remain a contentious issue in breast cancer surgery. Most notable is the difference between ‘no tumour on ink’ in many parts of the world, and 1 mm clear margin recommended in the UK. I have had many patients whose margin(s) was clear but < 1mm, so technically ‘no tumour on ink’ but they needed further surgery.
Despite our best efforts, about 18% (1 in 5/6 patients) will need further surgery to address margins after lumpectomy. It is more common after non-mass disease i.e. DCIS. The second surgery is usually a margin re-excision (shave), or in some cases can be mastectomy. This understandably is frustrating for the patient, who attends their results clinic hoping for the ‘all clear’, only to be told you need another surgery which might or might not achieve clearance. The number of additional operations also puts a strain on the health services and valuable theatre time.
There are a plethora of techniques and technologies aimed at reducing rate of margins being close or involved. These include taking extra margins at surgery, specimen imaging (X-ray, tomosynthesis, MRI), intra-operative ultrasound, special margin probes etc. The evidence supporting their use is not strong enough, they can be costly, or can lead to delays during surgery while examining the specimen.
Involved or close Margins remain an ongoing issue in breast cancer surgery and at the moment there is no well-established way of reducing this significantly. It is sadly the nature of the beast and I hope one day we can overcome this issue.
