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Factors affecting surgical margin positivity in invasive ductal breast cancer patients who underwent breast-conserving surgery after preoperative core biopsy diagnosis

Purpose The aim of our study is to evaluate the factors affecting surgical margin positivity among patients with invasive ductal breast cancer who underwent breast-conserving surgery (BCS) after preoperative diagnostic core biopsy. Methods Two hundred sixteen patients with stage I, II invasive ductal breast carcinoma who had histological diagnosis with preoperative tru-cut biopsy and underwent BCS were included in the present study. Potential factors that affect the positive surgical margin were analyzed. In univariate analysis, the comparisons of the factors affecting the surgical margin positivity were made by chi-square test. Logistic regression test was used to detect the independent factors affecting the surgical margin positivity. Results Positive axillary lymph node (odds ratio [OR], 8.2; 95% confidence interval [CI], 3.01 to 22.12), lymphovascular invasion (LVI; OR, 3.9; 95% CI, 1.62 to 9.24), extensive intraductal component (EIC; OR, 6.1; 95% CI, 2.30 to 16.00), presence of spiculation (OR, 5.1; 95% CI, 2.00 to 13.10) or presence of microcalcification in the mammography (OR, 13.7; 95% CI, 4.04 to 46.71) have been found to be the independent and adverse factors affecting surgical margin positivity. Conclusion Considering decision making for the extent of the excision and for achieving negative surgical margin before BCS, positive axillary lymph node, LVI, EIC, spiculation or microcalcification in mammography are related as predictor factors for positive surgical margin.


INTRODUCTION
The National Institute of Health (NIH) Consensus Conference in 1990 concluded that breast conservation surgery (BCS) was an appropriate method of treatment for women with early-stage breast cancers (stages I and II).
BCS has been increasingly performed for patients with early breast cancer since the NIH Consensus Conference [1].
The objective of BCS is to completely remove the breast cancer and achieve negative surgical margins while maintaining the best possible breast cosmesis. Surgical margin positivity is the most important factor for local recurrence after BCS [2][3][4]. BCS after tru-cut biopsy is known to be more efficient in providing negative surgical margin compared with excisional biopsy [5][6][7]. We used tru-cut biopsy, except in special cases, as the primary histological diagnostic method in our clinic. The data on the factors associated with surgical margin positivity and BCS for invasive ductal cancer in the setting of preoperative tru-cut biopsy are limited [8]. The purpose of the present study is to evaluate the factors affecting surgical margin positivity among patients with invasive ductal breast cancer who underwent BCS after preoperative tru-cut biopsy.

General characteristics of the patients have been given
in Positive surgical margin was detected in 58 patients (27%). In the univariate analysis (Table 1)  The findings of our study revealed that metastatic axillary lymph nodes, LVI, EIC, spiculated mass or microcalcifications in mammography were associated with positive surgical margin after BCS. Young age [12][13][14], high grade [15], and high density of the breast [16] have been reported as factors affecting positive surgical margin after BCS. Contrary to these studies, in some studies it has been shown that young age [17,18] and grade [6,19] do not have any influence on surgical margin positivity. These factors have also been found not significant in the present study.
In studies where the tumor size was analyzed, it has been reported that it affected surgical margin positivity [20,21].
In the present study; while the tumor size was important in univariate analysis, in multivariate analysis it lost significance. EIC [22][23][24] and LVI [3,22] were reported as significant factors associated with positive surgical margin in parallel with our study. Park et al. [25] have detected that patients who had 4 or more metastatic axillary lymph nodes had more positive surgical margins. In our study, we have found that metastatic axillary lymph node affected positive surgical margin significantly.
There are just a few studies analyzing the affect of the molecular subtypes of breast cancer on surgical margin positivity among patients who underwent BCS. Our findings do not agree with the study by Sioshansi et al. [9] who reported that triple negative breast cancer is associated with an increased risk of residual invasive carcinoma after lumpectomy. Atalay and Irkkan [26] have demonstrated that the presence of tumor in re-excision following BCS is significantly higher in patients with Her-2 (＋) subgroup.
However, Sioshani et al. [9] and Atalay et al. [26] analyzed the association of molecular subtypes with residual carcinoma, and with re-excision after lumpectomy, respectively, whereas we analyzed the association of subtypes with positive surgical margins.
Preoperative mammography could also have been used for decision making for the extent of excision in patients who are candidates for BCS. We agree with many studies that showed that the presence of microcalcification in mammography was an adverse factor affecting positive margin [27][28][29]. In our study, we have found that surgical margin positivity was significantly higher in patients who had a spicular appearance in mammography. However, a spiculated mass, which had been analyzed in only two studies, was not found to affect positive surgical margin [20,30].
Our findings support the findings of the study by Sioshansi et al. [9] who showed that multifocality is not significantly associated with an increased risk of residual invasive breast carcinoma, but contrast with the studies reporting that multifocality was as an adverse factor affecting positive surgical margin [21,27,29]. However, the number of patients with multifocality is very low in our series (3%); therefore, although surgical margin positivity is higher in patients with multifocal disease compared with those without multifocality (44% vs. 26%), this is not significant. Our study could lack the ability to show a difference at this level. Tumor location in breast quadrants was not found to be predictive of positive margins in our series as suggested by previous studies [6,30].
A limited study, found in the literature, analysed the factors affecting positive surgical margin among invasive breast cancer patients who had preoperative core or fine-needle biopsy was performed by Smitt and Horst [8].
In that study they reported that only lobular histology and LVI were significantly related with positive surgical margin among 67 invasive breast cancer patients who underwent preoperative diagnostic biopsy [8].

CONFLICTS OF INTEREST
No potential conflict of interest relevant to this article was reported.