Removing a Tiny Amount of Extra Tissue Around Margins Can Minimize Need
for Additional Surgery Later
Breast-conserving surgery – also known as lumpectomy or partial mastectomy
– is among the most common cancer surgeries performed in the United
States. According to a study published in 2012 in the Journal of the American
Medical Association (JAMA), an estimated 60 to 75 percent of breast cancer
patients undergo lumpectomy or partial mastectomy as their initial treatment.
“Physicians have been performing breast-conserving surgery on breast
cancer patients for decades,” says surgeon Dr. William Dugoni, medical
director of the Washington Women’s Center. “In breast-conserving
surgery, we remove the cancerous area and a surrounding margin of normal
tissue. The goal is to take just enough tissue so that the breast looks
as normal as possible after the surgery while the chance of the cancer
coming back is low. Radiation therapy is usually given after surgery for
several weeks. For early-stage breast cancer, breast-conserving surgery
combined with radiation therapy has the same survival rate as mastectomy.”
Unfortunately, the authors of the study published in JAMA noted that breast-conserving
procedures often require additional surgery (re-excision) if the margins
around the tumor contain cancer cells.
“Our results demonstrate an overall re-excision rate of 22.9 percent
that is lower than previous studies demonstrating re-excision rates of
36 to 50 percent,” the authors state. “(Another study) reported
a re-excision rate following initial breast-conserving therapy of 37.9
percent … with 26 percent undergoing partial breast re-excision
alone and 11.9 percent ultimately undergoing mastectomy.”
In 2012, the year that study was published in JAMA, the rate for Washington
Hospital patients undergoing partial breast re-excision alone was 10 percent,
and the overall re-excision rate (including those undergoing mastectomy)
was 13 percent. In both 2014 and 2015, Washington Hospital reported rates
of 3 percent for patients undergoing partial breast re-excision alone
and 10 percent for the overall re-excision rate (including those undergoing
mastectomy).
Dr. Dugoni credits both scientific thinking and surgical artistry for the
large difference between the nationally reported rates of re-excision
and the rates at Washington Hospital.
“I had become frustrated by the reports that one out of four women
nationally had to go back for re-excision after breast-conserving surgery,”
he explains. “These additional surgeries can cause significant emotional,
physical and economic stress for patients. When you have to go back into
the breast to take out more volume after the breast has already started
to heal, the cosmetic result is not as satisfactory. Plus, the need for
additional surgery has the potential to delay the use of other treatments,
including radiation therapy.
“So we developed a surgical procedure to take a little more tissue
around the edges of the margins during initial surgery,” he continues.
“I call it the ‘orange peel’ procedure, taking a tiny
bit more of the ‘rind’ around the cavity. In my opinion, that
is the ‘true margin’ of the tumor. The volume of the extra
tissue we remove is significantly less than we would have to take out
during a re-excision procedure, and the result is much more satisfactory
from a cosmetic standpoint. With 25 years of experience, I have been able
to fine-tune the surgical techniques, and it requires a certain amount
of artistry. We strive for negative margins, but we don’t want to
take out too much.”
Not all breast cancer patients are candidates for breast-conserving surgery,
Dr. Dugoni cautions.
“Women who are in the early stage of pregnancy cannot undergo radiation
therapy, so they are not good candidates for breast-conserving surgery,”
he says. “Breast-conserving surgery also is not a good option for
women who have multiple tumors clumped in one part of the breast or scattered
throughout the breast. Likewise, breast-conserving surgery would not work
well for women with a prior history of radiation treatment to the chest
or breast, or for those with a high genetic risk for breast cancer.
“Sometimes it’s just a matter of personal choice,” he
adds. “Some women opt to have a total mastectomy rather than breast-conserving
surgery. My ultimate goal is to protect my patients – physically,
emotionally and financially. I want to provide them with the best possible
treatment for their particular circumstances.”
Learn More
Washington Women’s Center offers advanced diagnostic services as
well as numerous wellness and support programs for local women. Accredited
by the National Accreditation Program for Breast Centers, Washington Women’s
Center is committed to providing the best possible care to patients with
diseases of the breast. For more information, visit www.whhs.com and click
on “Women’s Center” under the “Services”
tab at the top of the home page.
If you need help finding a physician, visit www.whhs.com and click on “Find
Your Physician.”