Original Research Article|Articles in Press

Factors influencing suboptimal pathologic margins and re-excision following breast conserving surgery for ductal carcinoma in-situ

Published:February 25, 2023DOI:


      • Patients undergoing BCS for DCIS have high rates of suboptimal pathologic margins (51.7%) and subsequent re-excision (27.8%).
      • Larger tumor size, younger patient age, lower tumor grade, and ER negative disease are all predictive of suboptimal margins.
      • These findings may increase surgeon insight as to considerations for mitigating this problem.



      Re-excisions following breast conserving surgery (BCS) are common, occurring more frequently in ductal carcinoma in-situ (DCIS) than its’ malignant counterpart. Although one quarter of patients with breast cancer will have DCIS, there is limited information available regarding factors predisposing to inadequate pathologic margins, and the need for re-excision.


      Retrospective review of patients treated for DCIS between the years 2010–2016 was conducted. Patients with DCIS undergoing BCS were identified and evaluated for demographic and pathologic factors associated with suboptimal pathologic margins and re-excision. Multivariate analysis with Wald Chi-Square testing was performed.


      241 patients underwent BCS with suboptimal margins (SOM) in 51.7% (123/238), with 27.8% undergoing re-excision (67/241). Tumor size was the most influential variable, positively associated with SOM (OR = 10.25, CI: 5.50–19.13) and re-excision (OR = 6.36, CI: 3.92–10.31). Patient age was inversely associated with SOM (OR = 0.58, CI: 0.39–0.85) and subsequent re-excisions (OR = 0.56, CI: 0.36–0.86). Low tumour grade was associated with re-excision (OR = 1.31, CI: 0.63–2.71), while ER negative disease was associated with SOM (OR = 2.24, CI: 1.21–4.14).


      Inadequate pathologic margins following BCS, and subsequent re-excision rates are common in patients with DCIS, and consistent with the literature. Tumour size is the dominant factor driving this occurrence, with patient age and tumour grade also impacting outcomes.


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        • Houvenaeghel G.
        • Lambaudie E.
        • Bannier M.
        • et al.
        Positive or close margins: reoperation rate and second conservative resection or total mastectomy?.
        CM. 2019; 11: 2507
        • Hughes L.
        • Hamm J.
        • McGahan C.
        • Baliski C.
        Surgeon volume, patient age, and tumor-related factors influence the need for re-excision after breast-conserving surgery.
        Ann Surg Oncol. 2016; 23: 656-664
        • Baliski C.
        • Bakos B.
        Patient reported outcomes following breast conserving surgery are improved by minimizing re-excisions and excessive breast tissue removal.
        Am J Surg. 2022; 224: 716
        • Baliski C.R.
        • Pataky R.E.
        Influence of the SSO/ASTRO margin reexcision guidelines on costs associated with breast-conserving surgery.
        Ann Surg Oncol. 2016; 24: 632-637
        • Lamb L.R.
        • Mercaldo S.
        • Oseni T.O.
        • Bahl M.
        Predictors of reexcision following breast-conserving surgery for ductal carcinoma in situ.
        Ann Surg Oncol. 2020; 28: 1390-1397
        • Choi S.H.
        • Choi J.S.
        • Han B.
        • Ko E.Y.
        • Ko E.S.
        • Park K.W.
        Long-term surveillance of ductal carcinoma in situ detected with screening mammography versus US: factors associated with second breast cancer.
        Radiology. 2019; 292: 37-48
        • Morrow M.
        • Van Zee K.J.
        • Solin L.J.
        • 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. 2016; 23: 3801
        • Jeevan R.
        • Cromwell D.A.
        • Trivella M.
        • et al.
        Reoperation rates after breast conserving surgery for breast cancer among women in england: retrospective study of hospital episode statistics.
        BMJ. 2012; 345e4505
        • Tamburelli F.
        • Ponzone R.
        The value of repeated breast surgery as a quality indicator in breast cancer care.
        Ann Surg Oncol. 2020; 28: 340-352
        • van Leeuwen M.T.
        • Falster M.O.
        • Vajdic C.M.
        • et al.
        Reoperation after breast-conserving surgery for cancer in Australia: statewide cohort study of linked hospital data.
        BMJ Open. 2018; 8e020858
        • Kryh C.G.
        • Pietersen C.A.
        • Rahr H.B.
        • Christensen R.D.
        • Wamberg P.
        • Lautrup M.D.
        Re-resection rates and risk characteristics following breast conserving surgery for breast cancer and carcinoma in situ: a single-centre study of 1575 consecutive cases.
        Breast. 2014; 23: 784-789
        • Wilke L.G.
        • Czechura T.
        • Wang C.
        • 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 surgery. 2014; 149: 1296-1305
        • Langhans L.
        • Jensen M.
        • Talman M.M.M.
        • Vejborg I.
        • Kroman N.
        • Tvedskov T.F.
        Reoperation rates in ductal carcinoma in situ vs invasive breast cancer after wire-guided breast-conserving surgery.
        JAMA Surg. 2017; : 152
        • So A.
        • De La Cruz L.M.
        • Williams A.D.
        • et al.
        The impact of preoperative magnetic resonance imaging and lumpectomy cavity shavings on re‐excision rate in pure ductal carcinoma in situ—a single institution's experience.
        J Surg Oncol. 2018; 117: 558-566
        • Mamtani A.
        • Romanoff A.
        • Baser R.
        • Vincent A.
        • Morrow M.
        • Gemignani M.L.
        Adoption of SSO-ASTRO margin guidelines for ductal carcinoma in situ: what is the impact on use of additional surgery?.
        Ann Surg Oncol. 2021; 28: 295-302
        • Howard-McNatt M.
        • Dupont E.
        • Tsangaris T.
        • et al.
        Impact of cavity shave margins on margin status in patients with pure ductal carcinoma in situ.
        J Am Coll Surg. 2021; 232: 373-378
        • Lepomäki M.
        • Karhunen‐enckell U.
        • Tuominen J.
        • et al.
        Tumor margins that lead to reoperation in breast cancer: a retrospective register study of 4,489 patients.
        J Surg Oncol. 2021; 125: 577
        • Mamtani A.
        • Romanoff A.
        • Baser R.
        • Vincent A.
        • Morrow M.
        • Gemignani M.L.
        Adoption of SSO-ASTRO margin guidelines for ductal carcinoma in situ: what is the impact on use of additional surgery?.
        Ann Surg Oncol. 2020; 28: 295-302
        • Sowerbutts A.M.
        • Griffiths J.
        • Todd C.
        • Lavelle K.
        Why Are Older Women Not Having Surgery for Breast Cancer? A Qualitative Study. vol. 24. Psycho-oncology, Chichester, England)2015: 1036-1042
        • Morgan J.L.
        • George J.
        • Holmes G.
        • et al.
        Breast cancer surgery in older women: outcomes of the bridging age gap in breast cancer study.
        Br J Surg. 2020; 107: 1468-1479
        • Valero M.G.
        • Mallory M.A.
        • Losk K.
        • et al.
        Surgeon variability and factors predicting for reoperation following breast-conserving surgery.
        Ann Surg Oncol. 2018; 25: 2573-2578
        • Walsh S.M.
        • Brennan S.B.
        • Zabor E.C.
        • et al.
        Does breast density increase the risk of re-excision for women with breast cancer having breast-conservation therapy?.
        Ann Surg Oncol. 2019; 26: 4246-4253
        • McCahill L.E.
        • Single R.M.
        • Aiello Bowles E.J.
        • et al.
        Variability in reexcision following breast conservation surgery.
        JAMA, J Am Med Assoc. 2012; 307: 467-475
        • Vicini F.A.
        • Shaitelman S.
        • Wilkinson J.B.
        • et al.
        Long-term impact of young age at diagnosis on treatment outcome and patterns of failure in patients with ductal carcinoma in situ treated with breast-conserving therapy.
        Breast J. 2013; 19: 365-373
        • Faverly D.R.
        • Burgers L.
        • Bult P.
        • Holland R.
        Three dimensional imaging of mammary ductal carcinoma in situ: clinical implications.
        Semin Diagn Pathol. 1994; 11: 193