What “No Ink on Tumor” Means If You Have Breast Cancer

Guideline aims to simplify surgery

new margin guidelines

Breast conservation. If you have breast cancer, these two words are meaningful. And thanks to advances in surgeries such as lumpectomy, they’re possible for more women than in the past.

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Breast-conserving surgery comes with questions, though. One of the biggest: How much healthy tissue should we remove around a tumor?

This has been controversial for years. All surgeons want to prevent your breast cancer from coming back. But there has been little agreement on the best “margins” around a tumor to reach that goal.

A guideline published earlier this year aims to change that. The Society of Surgical Oncology and American Society of Radiation Oncology analyzed years of data to reach these guidelines. The goals are better outcomes for patients with fewer operations.

“Your surgeon and your radiation oncologist will always make decisions based on your case and your needs.”

Stephen Grobmyer, MD

Director of Breast Services

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How radiologists measure tumors

To understand how margins work, you need to know how pathologists measure them.

First, a surgeon removes the section of the breast including the tumor. Then, a pathologist covers the removed tissue in permanent ink to mark the edges. Different colors of ink might indicate the top, bottom and sides.

Next, the pathologist slices the tissue into segments. Under a microscope, he or she can see how close the cancer extends to the inked margins. For example, is there 1 mm of noncancerous margin at the edge? Is there 2 mm? Different hospitals and surgeons relied on different measurements in the past to determine a successful operation for breast cancer.

The new guideline is simplified: no ink on tumor. When a pathologist looks at a mass, the cancer should not extend as far as the part that is covered with ink.

If a section of the tissue containing the tumor meets this guideline, patient outcomes are generally positive. If it does not, a hospital or surgeon may recommend a second operation to remove more tissue for safety’s sake.

How the change benefits patients

Simplicity doesn’t just matter for the people examining tumors. It also matters for the patients who have them.

For example, in the past, re-excision rates — re-excision means additional surgeries to remove more tissue — were all over the map. One study showed a re-excision range among surgeons from 0 percent to 70 percent. Most people agree the average is about 20 percent to 25 percent, which means that many patients were undergoing more than one operation as part of their treatment.

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Having a unified guideline should bring that rate down.

Patients prefer fewer operations, as it allows them a more rapid recovery and less risk of complications from surgery, so this is good news for them. It’s also good news for the healthcare system, because it should also help reduce costs.

In the end, it is only a guideline. Your surgeon and your radiation oncologist will always make decisions based on your case and your needs. But the guideline is a great place to start — for patients and for the team who cares for them.

More information


Stephen Grobmyer, MD

Stephen Grobmyer, MD

Stephen Grobmyer, MD, is Section Head of Surgical Oncology and the Director of Breast Services at Cleveland Clinic.
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