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Positive or Close Margins
Vilert Loving, MD; Wei Tse Yang, MBBS
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Clinical Issues

          TERMINOLOGY

          • Definitions

            • Positive margin: Presence of invasive carcinoma or DCIS at inked margin of resection
            • Focally positive margin: Cancer at margin over length of ≤ 4 mm or ≤ 3 low-power microscopic fields
            • Close margins: Usually defined as DCIS < 2 mm from inked surface
              • Not clinically relevant for invasive carcinoma where any negative margin is considered negative
            • True margin: Edge of resected tissue that directly faces tissue remaining in patient
            • Cavity margin: Additional tissue taken from edges of lumpectomy cavity
              • If true margins of cavity margins are negative for cancer, then margins are negative
              • Orienting specimens is critical; ink applied to true margin
            • Shaved margin: After breast-conserving surgery (BCS), additional tissue circumferentially resected ("shaved") around cavity, allowing examination of large portion of margin
              • Tumor cells in any piece considered positive margin
              • May overestimate positive margins as tumor cells in shaved piece may not be at true margin
            • Extensive intraductal component (EIC): DCIS represents ≥ 25% of main tumor mass within and adjacent to invasive tumor; includes microinvasive disease

          IMAGING

          • General Features

            • Mammographic Findings

              • Intraoperative Specimen Imaging

                • Ultrasonographic Findings

                  • MR Findings

                    • Imaging Recommendations

                      DIFFERENTIAL DIAGNOSIS

                        PATHOLOGY

                        • General Features

                          • Staging, Grading, & Classification

                            • Gross Pathologic & Surgical Features

                              • Microscopic Features

                                CLINICAL ISSUES

                                • Demographics

                                  • Natural History & Prognosis

                                    • Treatment

                                      DIAGNOSTIC CHECKLIST

                                      • Consider

                                        • Image Interpretation Pearls

                                          Selected References

                                          1. Chagpar AB et al: Do all positive margins in breast cancer patients undergoing a partial mastectomy need to be resected? J Am Coll Surg. 227(1):13-21, 2018
                                          2. Gray RJ et al: Intraoperative margin management in breast-conserving surgery: a systematic review of the literature. Ann Surg Oncol. 25(1):18-27, 2018
                                          3. Nayyar A et al: Definition and management of positive margins for invasive breast cancer. surg clin north am. 98(4):761-771, 2018
                                          4. Houssami N et al: Meta-analysis of pre-operative magnetic resonance imaging (MRI) and surgical treatment for breast cancer. Breast Cancer Res Treat. 165(2):273-283, 2017
                                          5. Karadeniz Cakmak G et al: Surgeon performed continuous intraoperative ultrasound guidance decreases re-excisions and mastectomy rates in breast cancer. Breast. 33:23-28, 2017
                                          6. Krammer J et al: Breast MR imaging for the assessment of residual disease following initial surgery for breast cancer with positive margins. Eur Radiol. 27(11):4812-4818, 2017
                                          7. Kuerer HM et al: DCIS margins and breast conservation: MD anderson cancer center multidisciplinary practice guidelines and outcomes. J Cancer. 8(14):2653-2662, 2017
                                          8. Vos EL et al: Omitting re-excision for focally positive margins after breast-conserving surgery does not impair disease-free and overall survival. Breast Cancer Res Treat. 164(1):157-167, 2017
                                          9. Lange M et al: The role of specimen radiography in breast-conserving therapy of ductal carcinoma in situ. Breast. 26:73-9, 2016
                                          10. Morrow M et al: Society of Surgical Oncology-American Society for Radiation Oncology-American Society of Clinical Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in ductal carcinoma in situ. Ann Surg Oncol. 23(12):3801-3810, 2016
                                          11. Chagpar AB et al: A randomized, controlled trial of cavity shave margins in breast cancer. N Engl J Med. ePub, 2015
                                          12. Fancellu A et al: Meta-analysis of the effect of preoperative breast MRI on the surgical management of ductal carcinoma in situ. Br J Surg. 102(8):883-93, 2015
                                          13. Patel BK et al: Does preoperative MRI workup affect mastectomy rates and/or re-excision rates in patients with newly diagnosed breast carcinoma? a retrospective review. Breast J. 21(6):604-9, 2015
                                          14. Moran MS et al: Society of Surgical Oncology-American Society for Radiation Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in stages I and II invasive breast cancer. Ann Surg Oncol. 21(3):704-16, 2014
                                          15. Sung JS et al: Preoperative breast MRI for early-stage breast cancer: effect on surgical and long-term outcomes. AJR Am J Roentgenol. 202(6):1376-82, 2014
                                          16. Wilke LG et al: Repeat surgery after breast conservation for the treatment of stage 0 to II breast carcinoma: a report from the National Cancer Data Base, 2004-2010. JAMA Surg. 149(12):1296-305, 2014
                                          17. Obdeijn IM et al: Preoperative breast MRI can reduce the rate of tumor-positive resection margins and reoperations in patients undergoing breast-conserving surgery. AJR Am J Roentgenol. 200(2):304-10, 2013
                                          18. Shin HC et al: Nomogram for predicting positive resection margins after breast-conserving surgery. Breast Cancer Res Treat. 134(3):1115-23, 2012
                                          19. Britton PD et al: Breast surgical specimen radiographs: how reliable are they? Eur J Radiol. 79:245-9, 2011
                                          20. Park S et al: The impact of a focally positive resection margin on the local control in patients treated with breast-conserving therapy. Jpn J Clin Oncol. 41(5):600-8, 2011
                                          21. Peters NH et al: Preoperative MRI and surgical management in patients with nonpalpable breast cancer: the MONET - randomised controlled trial. Eur J Cancer. 47(6):879-86, 2011
                                          22. Houssami N et al: Meta-analysis of the impact of surgical margins on local recurrence in women with early-stage invasive breast cancer treated with breast-conserving therapy. Eur J Cancer. 46(18):3219-32, 2010
                                          23. Stucky CC et al: Does magnetic resonance imaging accurately predict residual disease in breast cancer? Am J Surg. 198(4):547-52, 2009
                                          24. Houssami N et al: Accuracy and surgical impact of magnetic resonance imaging in breast cancer staging: systematic review and meta-analysis in detection of multifocal and multicentric cancer. J Clin Oncol. 26(19):3248-58, 2008
                                          25. Mercado CL et al: Sonographically guided marker placement for confirmation of removal of mammographically occult lesions after localization. AJR Am J Roentgenol. 191(4):1216-9, 2008
                                          26. Mazouni C et al: Specimen radiography as predictor of resection margin status in non-palpable breast lesions. Clin Radiol. 61(9):789-96, 2006
                                          27. Morris EA et al: Breast MRI: Diagnosis and Intervention. New York: Springer. 166, 214-26, 2005
                                          28. Chagpar AB et al: Lumpectomy margins are affected by tumor size and histologic subtype but not by biopsy technique. Am J Surg. 188(4):399-402, 2004
                                          29. Keskek M et al: Factors predisposing to cavity margin positivity following conservation surgery for breast cancer. Eur J Surg Oncol. 30(10):1058-64, 2004
                                          30. Lee JM et al: MRI before reexcision surgery in patients with breast cancer. AJR Am J Roentgenol. 182(2):473-80, 2004
                                          31. Chagpar A et al: Intraoperative margin assessment reduces reexcision rates in patients with ductal carcinoma in situ treated with breast-conserving surgery. Am J Surg. 186(4):371-7, 2003
                                          32. Dizendorf EV et al: Impact of whole-body 18F-FDG PET on staging and managing patients for radiation therapy. J Nucl Med. 44(1):24-9, 2003
                                          33. Meric F et al: Positive surgical margins and ipsilateral breast tumor recurrence predict disease-specific survival after breast-conserving therapy. Cancer. 97(4):926-33, 2003
                                          34. Singletary SE: Surgical margins in patients with early-stage breast cancer treated with breast conservation therapy. Am J Surg. 184(5):383-93, 2002
                                          35. Liberman L et al: Bracketing wires for preoperative breast needle localization. AJR Am J Roentgenol. 177(3):565-72, 2001
                                          36. Frei KA et al: MR imaging of the breast in patients with positive margins after lumpectomy: influence of the time interval between lumpectomy and MR imaging. AJR Am J Roentgenol. 175(6):1577-84, 2000
                                          37. Moore MM et al: Association of infiltrating lobular carcinoma with positive surgical margins after breast-conservation therapy. Ann Surg. 231(6):877-82, 2000
                                          38. Park CC et al: Outcome at 8 years after breast-conserving surgery and radiation therapy for invasive breast cancer: influence of margin status and systemic therapy on local recurrence. J Clin Oncol. 18(8):1668-75, 2000
                                          39. Waddell BE et al: Postexcision mammography is indicated after resection of ductal carcinoma-in-situ of the breast. Ann Surg Oncol. 7(9):665-8, 2000
                                          40. Jardines L et al: Factors associated with a positive reexcision after excisional biopsy for invasive breast cancer. Surgery. 118(5):803-9, 1995
                                          41. Graham RA et al: The efficacy of specimen radiography in evaluating the surgical margins of impalpable breast carcinoma. AJR Am J Roentgenol. 162(1):33-6, 1994
                                          42. Schnitt SJ et al: The relationship between microscopic margins of resection and the risk of local recurrence in patients with breast cancer treated with breast-conserving surgery and radiation therapy. Cancer. 74(6):1746-51, 1994
                                          43. Gluck BS et al: Microcalcifications on postoperative mammograms as an indicator of adequacy of tumor excision. Radiology. 188(2):469-72, 1993
                                          Related Anatomy
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                                          Related Differential Diagnoses
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                                          References
                                          Tables

                                          Tables

                                          KEY FACTS

                                          • Terminology

                                            • Imaging

                                              • Top Differential Diagnoses

                                                • Clinical Issues

                                                  TERMINOLOGY

                                                  • Definitions

                                                    • Positive margin: Presence of invasive carcinoma or DCIS at inked margin of resection
                                                    • Focally positive margin: Cancer at margin over length of ≤ 4 mm or ≤ 3 low-power microscopic fields
                                                    • Close margins: Usually defined as DCIS < 2 mm from inked surface
                                                      • Not clinically relevant for invasive carcinoma where any negative margin is considered negative
                                                    • True margin: Edge of resected tissue that directly faces tissue remaining in patient
                                                    • Cavity margin: Additional tissue taken from edges of lumpectomy cavity
                                                      • If true margins of cavity margins are negative for cancer, then margins are negative
                                                      • Orienting specimens is critical; ink applied to true margin
                                                    • Shaved margin: After breast-conserving surgery (BCS), additional tissue circumferentially resected ("shaved") around cavity, allowing examination of large portion of margin
                                                      • Tumor cells in any piece considered positive margin
                                                      • May overestimate positive margins as tumor cells in shaved piece may not be at true margin
                                                    • Extensive intraductal component (EIC): DCIS represents ≥ 25% of main tumor mass within and adjacent to invasive tumor; includes microinvasive disease

                                                  IMAGING

                                                  • General Features

                                                    • Mammographic Findings

                                                      • Intraoperative Specimen Imaging

                                                        • Ultrasonographic Findings

                                                          • MR Findings

                                                            • Imaging Recommendations

                                                              DIFFERENTIAL DIAGNOSIS

                                                                PATHOLOGY

                                                                • General Features

                                                                  • Staging, Grading, & Classification

                                                                    • Gross Pathologic & Surgical Features

                                                                      • Microscopic Features

                                                                        CLINICAL ISSUES

                                                                        • Demographics

                                                                          • Natural History & Prognosis

                                                                            • Treatment

                                                                              DIAGNOSTIC CHECKLIST

                                                                              • Consider

                                                                                • Image Interpretation Pearls

                                                                                  Selected References

                                                                                  1. Chagpar AB et al: Do all positive margins in breast cancer patients undergoing a partial mastectomy need to be resected? J Am Coll Surg. 227(1):13-21, 2018
                                                                                  2. Gray RJ et al: Intraoperative margin management in breast-conserving surgery: a systematic review of the literature. Ann Surg Oncol. 25(1):18-27, 2018
                                                                                  3. Nayyar A et al: Definition and management of positive margins for invasive breast cancer. surg clin north am. 98(4):761-771, 2018
                                                                                  4. Houssami N et al: Meta-analysis of pre-operative magnetic resonance imaging (MRI) and surgical treatment for breast cancer. Breast Cancer Res Treat. 165(2):273-283, 2017
                                                                                  5. Karadeniz Cakmak G et al: Surgeon performed continuous intraoperative ultrasound guidance decreases re-excisions and mastectomy rates in breast cancer. Breast. 33:23-28, 2017
                                                                                  6. Krammer J et al: Breast MR imaging for the assessment of residual disease following initial surgery for breast cancer with positive margins. Eur Radiol. 27(11):4812-4818, 2017
                                                                                  7. Kuerer HM et al: DCIS margins and breast conservation: MD anderson cancer center multidisciplinary practice guidelines and outcomes. J Cancer. 8(14):2653-2662, 2017
                                                                                  8. Vos EL et al: Omitting re-excision for focally positive margins after breast-conserving surgery does not impair disease-free and overall survival. Breast Cancer Res Treat. 164(1):157-167, 2017
                                                                                  9. Lange M et al: The role of specimen radiography in breast-conserving therapy of ductal carcinoma in situ. Breast. 26:73-9, 2016
                                                                                  10. Morrow M et al: Society of Surgical Oncology-American Society for Radiation Oncology-American Society of Clinical Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in ductal carcinoma in situ. Ann Surg Oncol. 23(12):3801-3810, 2016
                                                                                  11. Chagpar AB et al: A randomized, controlled trial of cavity shave margins in breast cancer. N Engl J Med. ePub, 2015
                                                                                  12. Fancellu A et al: Meta-analysis of the effect of preoperative breast MRI on the surgical management of ductal carcinoma in situ. Br J Surg. 102(8):883-93, 2015
                                                                                  13. Patel BK et al: Does preoperative MRI workup affect mastectomy rates and/or re-excision rates in patients with newly diagnosed breast carcinoma? a retrospective review. Breast J. 21(6):604-9, 2015
                                                                                  14. Moran MS et al: Society of Surgical Oncology-American Society for Radiation Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in stages I and II invasive breast cancer. Ann Surg Oncol. 21(3):704-16, 2014
                                                                                  15. Sung JS et al: Preoperative breast MRI for early-stage breast cancer: effect on surgical and long-term outcomes. AJR Am J Roentgenol. 202(6):1376-82, 2014
                                                                                  16. Wilke LG et al: Repeat surgery after breast conservation for the treatment of stage 0 to II breast carcinoma: a report from the National Cancer Data Base, 2004-2010. JAMA Surg. 149(12):1296-305, 2014
                                                                                  17. Obdeijn IM et al: Preoperative breast MRI can reduce the rate of tumor-positive resection margins and reoperations in patients undergoing breast-conserving surgery. AJR Am J Roentgenol. 200(2):304-10, 2013
                                                                                  18. Shin HC et al: Nomogram for predicting positive resection margins after breast-conserving surgery. Breast Cancer Res Treat. 134(3):1115-23, 2012
                                                                                  19. Britton PD et al: Breast surgical specimen radiographs: how reliable are they? Eur J Radiol. 79:245-9, 2011
                                                                                  20. Park S et al: The impact of a focally positive resection margin on the local control in patients treated with breast-conserving therapy. Jpn J Clin Oncol. 41(5):600-8, 2011
                                                                                  21. Peters NH et al: Preoperative MRI and surgical management in patients with nonpalpable breast cancer: the MONET - randomised controlled trial. Eur J Cancer. 47(6):879-86, 2011
                                                                                  22. Houssami N et al: Meta-analysis of the impact of surgical margins on local recurrence in women with early-stage invasive breast cancer treated with breast-conserving therapy. Eur J Cancer. 46(18):3219-32, 2010
                                                                                  23. Stucky CC et al: Does magnetic resonance imaging accurately predict residual disease in breast cancer? Am J Surg. 198(4):547-52, 2009
                                                                                  24. Houssami N et al: Accuracy and surgical impact of magnetic resonance imaging in breast cancer staging: systematic review and meta-analysis in detection of multifocal and multicentric cancer. J Clin Oncol. 26(19):3248-58, 2008
                                                                                  25. Mercado CL et al: Sonographically guided marker placement for confirmation of removal of mammographically occult lesions after localization. AJR Am J Roentgenol. 191(4):1216-9, 2008
                                                                                  26. Mazouni C et al: Specimen radiography as predictor of resection margin status in non-palpable breast lesions. Clin Radiol. 61(9):789-96, 2006
                                                                                  27. Morris EA et al: Breast MRI: Diagnosis and Intervention. New York: Springer. 166, 214-26, 2005
                                                                                  28. Chagpar AB et al: Lumpectomy margins are affected by tumor size and histologic subtype but not by biopsy technique. Am J Surg. 188(4):399-402, 2004
                                                                                  29. Keskek M et al: Factors predisposing to cavity margin positivity following conservation surgery for breast cancer. Eur J Surg Oncol. 30(10):1058-64, 2004
                                                                                  30. Lee JM et al: MRI before reexcision surgery in patients with breast cancer. AJR Am J Roentgenol. 182(2):473-80, 2004
                                                                                  31. Chagpar A et al: Intraoperative margin assessment reduces reexcision rates in patients with ductal carcinoma in situ treated with breast-conserving surgery. Am J Surg. 186(4):371-7, 2003
                                                                                  32. Dizendorf EV et al: Impact of whole-body 18F-FDG PET on staging and managing patients for radiation therapy. J Nucl Med. 44(1):24-9, 2003
                                                                                  33. Meric F et al: Positive surgical margins and ipsilateral breast tumor recurrence predict disease-specific survival after breast-conserving therapy. Cancer. 97(4):926-33, 2003
                                                                                  34. Singletary SE: Surgical margins in patients with early-stage breast cancer treated with breast conservation therapy. Am J Surg. 184(5):383-93, 2002
                                                                                  35. Liberman L et al: Bracketing wires for preoperative breast needle localization. AJR Am J Roentgenol. 177(3):565-72, 2001
                                                                                  36. Frei KA et al: MR imaging of the breast in patients with positive margins after lumpectomy: influence of the time interval between lumpectomy and MR imaging. AJR Am J Roentgenol. 175(6):1577-84, 2000
                                                                                  37. Moore MM et al: Association of infiltrating lobular carcinoma with positive surgical margins after breast-conservation therapy. Ann Surg. 231(6):877-82, 2000
                                                                                  38. Park CC et al: Outcome at 8 years after breast-conserving surgery and radiation therapy for invasive breast cancer: influence of margin status and systemic therapy on local recurrence. J Clin Oncol. 18(8):1668-75, 2000
                                                                                  39. Waddell BE et al: Postexcision mammography is indicated after resection of ductal carcinoma-in-situ of the breast. Ann Surg Oncol. 7(9):665-8, 2000
                                                                                  40. Jardines L et al: Factors associated with a positive reexcision after excisional biopsy for invasive breast cancer. Surgery. 118(5):803-9, 1995
                                                                                  41. Graham RA et al: The efficacy of specimen radiography in evaluating the surgical margins of impalpable breast carcinoma. AJR Am J Roentgenol. 162(1):33-6, 1994
                                                                                  42. Schnitt SJ et al: The relationship between microscopic margins of resection and the risk of local recurrence in patients with breast cancer treated with breast-conserving surgery and radiation therapy. Cancer. 74(6):1746-51, 1994
                                                                                  43. Gluck BS et al: Microcalcifications on postoperative mammograms as an indicator of adequacy of tumor excision. Radiology. 188(2):469-72, 1993