Updates and Debate Concerning Margin Adequacy and Management following Breast-Conserving Surgery

Objective: Breast-conserving surgery (BCS) experienced a significant surge during the last decades due to the increase of early breast cancer detection. Central to the discussion is margin adequacy which represents one of the most significant predictive factors for local relapse. This paper aims to shed light on the problem of margins in breast surgery. Mechanism: We performed a systematic narrative review of the literature by conducting a search using Medline/PubMed, Scopus, and Embase. The following keywords were considered: “breast-conserving surgery” AND “margins”/“margin”. Findings in Brief: In the case of invasive breast cancer, “no ink on tumor” can be considered an adequate margin, while for ductal carcinoma in situ (DCIS), a distance of 2 mm from tumor should be obtained. Many novel tools have been developed based both on the latest radiological imaging techniques and on the tissue expression of certain markers, with the aim of precise navigation of tumor excision and intraoperative evaluation of cavity excision margins. Oncoplastic surgery can be considered oncologically safe while improving the cosmetic outcome and patients’ quality of life. The appropriate use of adjuvant treatments in the context of a multidisciplinary and personalized management of breast cancer is the only means to omit a second intervention in some carefully selected cases. Conclusions: Debate still exists concerning the definition of adequate clear margin following BCS for DCIS. Further studies are required to better assess multimodal treatment approaches in this condition

Third national surgical consensus conference of the Italian Association of Breast Surgeons (ANISC) on management after neoadjuvant chemotherapy: The difficulty in reaching a consensus

Introduction: Neoadjuvant chemotherapy (NAC) has a profound impact on surgical management of breast cancer. For this reason, the Italian Association of Breast Surgeons (ANISC) promoted the third national Consensus Conference on this subject, open to multidisciplinary specialists. Materials and methods: The Consensus Conference was held on-line in November 2022, and after an introductory session with five core-team experts, participants were asked to vote on eleven controversial issues, while results were collected in real-time with a polling system. Results: A total of 164 dedicated specialists from 74 Breast Centers participated. Consensus was reached for only three of the eleven issues, including: 1) the indication to assess the response with Magnetic Resonance Imaging (79 %); 2) the need to re-assess the biological factors of the residual tumor if present (96 %); 3) the possibility of omitting a formal axillary node dissection for cN1 patients if a pathologic Complete Response (pCR) was confirmed with analysis of one or more sentinel lymph nodes (82 %). The majority voted in favor of mapping both the breast and nodal lesions pre-NAC (59 %), and against the omission of sentinel lymph node biopsy in cN0 patients in the case of pathologic or clinical Complete Response (69 %). In cases of cT3/cN1+ tumors with pCR, only 8 % of participants considered appropriate the omission of Post-Mastectomy Radiation Therapy. Conclusion: There is still a wide variability in surgical approaches after NAC in the "real world". As NAC is increasingly used, multidisciplinary teams should be attuned to conforming their procedures to the rapid advances in this field