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. 2025 Mar 6;4(1):e000633.
doi: 10.1136/bmjonc-2024-000633. eCollection 2025.

Impact of resection margin width on local recurrence following breast-conserving surgery and whole breast radiotherapy for pure ductal carcinoma in situ: a systematic review and meta-analysis

Ahmed Ezzat  1   2 , Dhurka Shanthakumar  1 , Naomi Laskar  1   2 , Ramsey I Cutress  3 , Dimitri Hadjiminas  1   2 , Michael Boland  2 , Meera Joshi  1   2 , Ronak Patel  1 , Yasmin Grant  1 , Ravi Naik  1 , Nur Amalina Che Bakri  1 , Saur Hajev  1 , Hussein Elghazaly  1 , Josephine Holt  4 , Alfie Roddan  1 , Susan Cleator  1   2 , Ara Darzi  1 , Hutan Ashrafian  1 , Daniel R Leff  1   2
Affiliations

Impact of resection margin width on local recurrence following breast-conserving surgery and whole breast radiotherapy for pure ductal carcinoma in situ: a systematic review and meta-analysis

Ahmed Ezzat et al. BMJ Oncol. .

Abstract

Objective: The aim of this study was to determine the impact of margin width and boost radiotherapy on the local recurrence risk of pure ductal carcinoma in situ (DCIS).

Methods and analysis: This is a prospectively registered systematic review and meta-analysis reporting relative risk (RR), OR and HR margin width outcomes. Eligible studies included prospective and retrospective case series with defining margin widths and 48 months of minimum follow-up. All patients (100%) received adjuvant whole breast radiotherapy (WBRT).

Results: A total of 40 265 patients with pure DCIS in 31 studies were included. ORs and RR were calculated from 15 studies in 12 519 patients, and HRs were calculated from 12 studies in 12 946 patients. Local recurrence was significantly greater with narrower 'close' margins; 0.1-1 mm versus >1 mm in RR (2.88, 95% CI 1.86 to 3.90; p<0.05), OR (4.82, 95% CI 2.45 to 9.48; p<0.05) and HR analysis (1.34, 95% CI 1.01 to 1.67; p<0.05). Compared with margins >2 mm, significantly greater local recurrence was observed in margins 0.1-2 mm in RR (1.72, 95% CI 1.09 to 2.35; p<0.05) and OR (4.43, 95% CI 3.02 to 6.50; p<0.05). Comparing 0.1-1 mm versus >1 mm and 0.1-2 mm versus >2 mm, differences in local recurrence were not statistically significant, once adjusted for boost radiotherapy.

Conclusions: In pure DCIS with WBRT, the local recurrence risk reduces as margin width increases up to 2 mm. The strength of the recommendation for a minimum clear margin of 2 mm is limited by a lack of data comparing 1.1-2 mm with >2 mm. The association between recurrence and close margins is not significant following boost radiotherapy, suggesting a possible alternative to re-excision in patients with close margins <2 mm.

Systematic review registration: CRD42022308524.

Keywords: Breast cancer (female); Radiation oncology.

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Conflict of interest statement

RIC declares institutional research funding from SECA and Astra-Zeneca which do not relate to this original research. HA is Chief Scientific Officer, Preemptive Health and Medicine, Flagship Pioneering who does not relate to this original research. The remaining authors declare no conflict of interest.

Figures

Figure 1
Figure 1. Reporting the relative risk for local recurrence in patients undergoing breast-conserving surgery with whole breast radiotherapy. bRT, boost radiotherapy based on comparisons between different margin widths; I2, heterogeneity score; n, number of patients with local recurrence; N, total number of patients within the margin width group.
Figure 2
Figure 2. Reporting the OR for local recurrence in patients undergoing breast-conserving surgery with whole breast radiotherapy, based on comparisons between different margin widths. I2, heterogeneity score; n, number of patients with local recurrence; N, total number of patients within the margin width group.
Figure 3
Figure 3. Reporting the HR for local recurrence in patients undergoing breast-conserving surgery with whole breast radiotherapy, based on comparisons between different margin widths. I2, heterogeneity score; N, total number of patients within the margin width group
Figure 4
Figure 4. Reporting forest plot meta-analysis of local recurrence risk outcomes in patients undergoing breast-conserving surgery with whole breast radiotherapy, based on comparisons between different margin widths. A. OR. B. RR. C. RR comparing 0.1–1 mm versus >1 mm*bRT D. RR comparing 0·1–2 mm versus >2 mm*bRT. E. HR. bRT, adjusted for boost radiotherapy; RR, relative risk; TOI, tumour on ink.
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