Breast cancer has a significant health challenge, affecting millions of women around the world. For better knowing , understanding breast cavity margins is necessary. Adequate margins are very important in breast-conserving surgery (BCS) to ensure that cancer cells are completely removed. They have a significant role in determining a successful surgery, during the excision of breast tissue and the likelihood of cancer returning.
Surgeons need to ensure that they achieve “clean” margins status, which means that no cancer cells are detected at the edges of the removed tissue. Understanding these margins for ensuring complete removal of cancer tissue and minimizing the risk of recurrence, can be very useful. Let’s break it down to know what they are exactly.
Understanding Breast Cavity Margins
The examination of margins has become an essential component of breast cancer surgery. Breast cavity margins refer to the boundaries surrounding the cavity during the removal of breast tissue, primarily in lumpectomy or mastectomy actions. After the surgery when tumor is taken out, doctors examine these margins to see whether there are any cancer cells present. The cavity margins examination is a critical part of surgery, effecting treatment decisions or subsequent therapies. The result will show three types of margins, negative or positive, that are classified as below:
– Negative Margins: It means no cancer cells are found at the edges of the removed tissue, referring that the tumor has entirely excised. Negative margins have been associated with long-term survival rates and reduced need for additional surgeries, including re-excision or mastectomy after initial lumpectomy.
– Positive Margins: In contrast, positive margins means that cancer cells are be still present at the edges, and leads the patient to the additional treatment. For instance, without adequate margins, the possibility of recurrence can be as high as 30-40% within five years post-surgery.
– Close Margins: This is seen when the cancer cells are very close to the edge but does not touching. The risk of recurrence of this type is higher than negative margins but not as certain as positive ones. These are neither positive nor negative but are within a certain distance (often defined as <1mm) from the tumor; they mostly need further investigation.
Margin Assessment Techniques
Medical studies have shown some techniques are effective and useful for removing the cancer cells during the surgery:
1- One of the methods that gives feedback immediately, is Frozen Section Analysis. In this analysis, a part of the removed tissue is frozen to examine under the microscope.
2- Cancer Diagnostic Probe (CDP), a real-time system which can help detect pre-cancerous or cancerous cells in breast cancer margins during surgery. This device can check the margins, such as Superior, Inferior, Medial, Lateral, Superficial, and Posterior (deep). The CDP can deeply affect improve the accuracy of the removed breast tissue by recognizing the involved breast cavity margins that may be missed by frozen pathology .
3- A Gamma Probe device can be used to help identify the tumor and verify the presence of the margins. Gamma Probe is the first stereotactic body radiation therapy (SBRT) system optimized for treating breast cancer.
4- The Margin Probe is a device that helps identify cancerous tissue at the margins of breast tissue during lumpectomy surgery, and can reduce the number of patients who need to have additional surgery to remove more tissue.
5- When the excised tissue is analyzed for cancer cells presence, Touch Preparation Cytology can provide additional insights, although this technique is less common.
6- Using intraoperative imaging devices during surgeries can help surgeons visualize margins better:
- Intraoperative Ultrasound: This technique provides imaging during the procedure, allowing surgeons to visualize margins and assess whether all cancerous tissue has been removed.
- Fluorescence Imaging: Using fluorescent markers that verify the tumor cells, helps surgeons to identify cancerous tissue during the surgical procedure, helping to ensure complete removal.
Treatment Decisions
The status of breast cavity margins can lead the patients to subsequent treatment plan. When the margins are positive, doctors usually recommend additional treatment options, that include:
– Re-excision: Another surgery for removing more tissue, aim to clear the remaining margins. Not only this increases physical and emotional distress for patients but also leads to longer recovery times and hidden costs for healthcare systems.
– Radiation Therapy: This treatment targets all cancer cells in the area.
– Chemotherapy or Hormonal Therapy: Based on the type and stage of the breast cancer, it can be recommended to reduce the risk of recurrence.
– Psychological Impact: Due to the anxiety and uncertainty surrounding recurrence of the cancer, a significant psychological burden on patients may occur. Those who receive negative margin results usually experience a reduction in anxiety and an improved sense of wellbeing.
Risk Factors for Positive Margins
Understanding risk factors can help patients manage their specific situation by talking to their doctors. Several factors can increase the likelihood of positive margins, are:
– Size of the Tumor: To complicate margin status, large tumors require more extensive removal.
– Tumor Location: The location of the tumor when it is near the skin, chest wall or underlying muscle present a greater challenge for clearing the margins entirely.
– Patient Age and Genetic Factors: Younger individuals might present with more aggressive tumor types, while genetic predispositions can affect tumor behavior and margin involvement.
– Biopsy Type: Different techniques for obtaining tissue samples can affect the margins at the time of surgery.
– Previous Surgeries: Patients who has a experience of breast surgeries can influence the altered anatomy or scar tissue, to complicate margin assessment.
– Histological Type: Different types of breast cancer (e.g., invasive ductal carcinoma, lobular carcinoma) may spread in various patterns, impacting margin clearance. Some tumors exhibit diffuse infiltration, making it difficult for the surgeon to identify the boundaries of cancer cells in breast tissue.
– Surgeon History: The experience of the doctors and surgeons can impact hardly for achieving to successful results such as negative margins.
Current Guidelines and Recommendations
According to breast cancer news, several organizations provide guidelines on the management of breast cavity margins. One of those organizations is American Society of Clinical Oncology (ASCO) that suggests a margin with at least 2 mm is ideal for invasive breast cancer. Another valid organization, National Comprehensive Cancer Network (NCCN) shows that margins should be assessed according to tumor type and patient potential risk factors. Then at the end, SSO (Society of Surgical Oncology) recommends adopting the “no ink on the tumor” as the definition of a negative margin for invasive breast cancer undergoing lumpectomy.
There is also a medical study between 2021 and 2023, in which 594 patients were enrolled in study for breast cavity margins and ended up with a remarkable result in this field. The cavity shaving result after lumpectomy reduced the rate of positive margins and it was associated with a large amount of reduction in surgical time compared to intraoperative evaluation of resection margins.
Significance of Follow-Up Care
Effective management of breast cavity margins doesn’t end with surgery. Scheduled follow-up cares, like maintaining a balanced diet, engaging in regular physical activities, and avoiding smoking is vital for monitoring recurrence signs after any surgery procedure, and managing any complications arising from the surgery. Patients should be informed about individualized screening protocols including MRI scans or mammograms or other imaging modalities depending on their risk profile to catch any potential recurrences early.
This involves regular check-ups and imaging tests to catch any signs of cancer cells or recurrence. In this process, doctors will often evaluate breast health and recommend ongoing screening plans, and even psychological and social support services can help patients deal with their treatment and diagnosis procedures, ultimately leading to improved quality of life. Staying proactive about these appointments is important for having long-term health.
Conclusion
Breast cavity margins are a crucial aspect of breast cancer surgical management. Clear negative margins are vital to minimize the risk of cancer recurrence. Through medical studies, with the ongoing advancements in surgical techniques and the increasing understanding of tumor biology, achieving adequate margins has become more attainable. Various factors, such as tumor size and location, can impact margin status, and optimal outcomes.
On-going assessment methods enhance our understanding and management of breast cancer treatments. Having a follow-up care plan and staying informed about new techniques can further impact outcomes. In the end, if you are a patient or a loved one of someone facing this path, please notice that staying proactive and energetic makes a great difference in fighting against the breast cancer.
Sources:
https://www.mdpi.com/1718-7729/31/1/35
https://aacrjournals.org/cancerres/article
https://www.sciencedirect.com/science/article
https://healthcare-in-europe.com/en/news/fluorescence-guided-surgery-breast-cancer-margins.html
