Impact of intraoperative margin optimization strategies compared to standard breast-conserving surgery on oncologic outcomes: a systematic review and meta-analysis of randomized and prospective trials

Achieving optimal surgical margins is critical in breast-conserving surgery (BCS) to reduce local recurrence (LR) and the need for re-excision. This meta-analysis evaluated the impact of intraoperative margin optimization strategies on key surgical and oncologic outcomes in patients who underwent BCS. A systematic review and meta-analysis were conducted according to the PRISMA guidelines, including six randomized controlled trials (RCTs). The outcomes assessed included the re-excision rate (primary outcome), positive margin rate, local recurrence (LR), and overall survival (OS). The risk of bias was evaluated using the ROB 2 tool, and the certainty of evidence was assessed using GRADE. The study protocol was prospectively registered in the PROSPERO database ( CRD420251000564 ). Intraoperative margin optimization significantly reduced re-excision rates (OR 0.54, 95% CI 0.32-0.90), corresponding to 169 fewer re-excisions per 1,000 patients. Positive margin rates were also significantly lower (OR 0.40, 95% CI 0.22-0.73), translating to 139 fewer positive margins per 1,000 patients. No statistically significant differences were observed for LR (OR 0.72, 95% CI, 0.16-3.19) or OS (OR 0.87, 95% CI, 0.73-1.03). Intraoperative margin optimization effectively reduces positive margins and re-excisions in BCS without adversely affecting LR or OS. The incorporation of these strategies should be considered a standard practice to enhance surgical quality and patient outcomes.