Table 2.
Summary of the prognostic implications, adjuvant treatment recommendations, and associated cost estimates of PSM for individual tumor sites: breast, prostate, bladder, colon and rectum, thyroid, oral cavity, lung and bronchus, uterine.
| BREAST | PROSTATE | BLADDER | COLON & RECTUM | ||
|---|---|---|---|---|---|
| Prognostic Implications for PSM | Increased LRR, decreased DSS | Increased risk of biochemical recurrence; no impact on cancer-specific mortality | Increased LRR, Decreased DSS | Increased LRR and DM, decreased DFS and OS | |
| Adjuvant Treatment Recommendations for PSM based on NCCN Guidelines | Early Stage | PSM after lumpectomy: Re-excision OR Mastectomy OR Higher RT boost for focal PSM without extensive intraductal component |
RT | Stage II (T2N0) RT, OR Chemo (if no neoadjuvant therapy) Stage II (T2N0) primary urethra carcinoma (males): Re-resection Or CRT (preferred) Or RT |
Colon: larger resection, T3N0M0 chemo, and for any stage consider boost radiation |
| Late Stage | PSM after mastectomy: Consider RT to chest wall +/− infraclavicular region +/− supraclavicular area +/− internal mammary nodes &any part of axillary bed at risk |
RT | Stage III-IV (T3–4, N0-2) urothelial: Higher RT boost |
Rectum: larger resection, T1Nx after trans-anal excision: Transabdominal resection +/− CRT or CRT, and intra-operative radiation therapy (IORT) may be considered for PSM especially in T4 and recurrent cancers |
|
| Cost of Adjuvant Treatment due to PSM | Surgery | Lumpectomy alone: $70,520 Mastectomy alone: $48,258 Mastectomy + Recon: $88,089 |
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| Radiation | RT: $8,600 | RT: $18,000 | |||
| Chemotherapy | Chemo: $16,416 | Chemo: $17,833 | |||
| THYROID | ORAL CAVITY | LUNG & BRONCHUS | UTERINE | ||
| Prognostic Implications for PSM | No impact | Increased LRR, Decreased OS | Decreased OS | Potential increase in LRR | |
| Adjuvant Treatment Recommendations for PSM based on NCCN guidelines | Early Stage | PSM after partial thyroidectomy (papillary): Completion thyroidectomy | STAGE I-II: Re-resection OR RT OR CRT (T2 only) |
STAGE IA: Re-resection (preferred) OR RT (category 2B) STAGE IB-IIA (node-negative): Re-resection (preferred) +/− chemo OR RT +/− chemo (chemo for stage IIA) STAGE IIA-B (node-positive): Re-resection+ chemo OR CRT |
Vaginal brachytherapy and/or RT for stage I after extrafascial hysterectomy |
| Late Stage | STAGE III-IV CRT (category 1) OR Re-resection OR RT |
STAGE IIIA: CRT | T1, Nx rectal after trans-anal excision: Transabdominal resection +/− CRT OR CRT |
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| Cost of Adjuvant Treatment due to PSM | Surgery | Surgery: $5,617 | Surgery: $24,595 | Surgery: $15,034 | |
| Radiation | RT: $21,300 | RT: $9,000 | RT: $9066 Brachytherapy: $7233 |
||
| Chemotherapy | Chemo + RT: $27,928 |
*Unless otherwise specified, recommendations are category 2 A (uniform NCCN consensus that intervention is appropriate based on lower-level evidence). Kidney and Ovarian excluded as surgical margin status does not affect adjuvant therapy recommendations.
**Cost for adjuvant treatment was obtained from published data in the United States (listed in U.S. dollars) where available.
NCCN: National Comprehensive Cancer Network, PSM: positive surgical margin, RT: radiation therapy; chemo: chemotherapy, CRT: chemoradiation; LRR: locoregional recurrence rate, DSS: disease-specific survival, DM: distant metastasis, DFS: disease-specific survival, OS: overall survival.