Kestin L L, Goldstein N S, Lacerna M D, Balasubramaniam M, Martinez A A, Rebner M, Pettinga J, Frazier R C, Vicini F A
Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI 48073, USA.
Cancer. 2000 Feb 1;88(3):596-607. doi: 10.1002/(sici)1097-0142(20000201)88:3<596::aid-cncr16>3.0.co;2-n.
The authors reviewed their institution's experience treating patients with mammographically detected ductal carcinoma in situ (DCIS) of the breast with breast-conserving therapy (BCT) to determine 10-year rates of local control and survival and to identify factors associated with local recurrence.
From January 1980 to December 1993, 132 breasts in 130 patients were treated with BCT for mammographically detected DCIS at William Beaumont Hospital, Royal Oak, Michigan. All patients underwent an excisional biopsy, and 64% were reexcised. All patients received postoperative whole-breast irradiation to a median dose of 45.0 Gray (Gy) (range: 43.1-56.0 Gy). One hundred twenty-four cases (94%) received a boost to the tumor bed for a median total dose of 60.4 Gy (range: 45.0-71.8 Gy). All cases underwent complete pathologic review by one pathologist. The median follow-up was 7.0 years.
Of the entire study group, 13 patients developed recurrence within the ipsilateral breast, for 5- and 10-year actuarial rates of 8.9% and 10.3%, respectively. Nine of the 13 recurrences (69%) occurred within or immediately adjacent to the lumpectomy cavity and were designated as true recurrences or marginal misses (TR/MM). Four patients (31%) had recurrence elsewhere in the breast. Ten of the 13 recurrences (77%) were invasive, whereas 3 (23%) were pure DCIS. Only 1 patient died of disease, corresponding to 5- and 10-year actuarial cause specific survival rates of 100% and 99.0%, respectively. Multiple clinical, pathologic, and treatment-related factors were analyzed for association with ipsilateral breast failure or TR/MM. In multivariate analysis, only the absence of pathologic calcifications was significantly associated with ipsilateral breast failure. When specifically analyzed for TR/MM, younger age at diagnosis, number of slides with DCIS, number of DCIS and cancerization of lobules (COL) foci within 5 mm of the margin, and the absence of pathologic calcifications demonstrated a statistically significant association. Close or positive margin status did not significantly predict for either TR/MM (P = 0.14) or ipsilateral breast failure (P = 0.19).
In patients with mammographically detected DCIS treated with BCT, adequate excision of all DCIS prior to RT can result in improved rates of local control. However, margin status may not adequately predict complete tumor extirpation. The volume of DCIS within 5 mm of the margin appears to be a more reliable surrogate for the adequacy of excision. In addition, young patient age and the absence of pathologic calcifications are independent risk factors for the development of local recurrence.
作者回顾了其所在机构采用保乳治疗（BCT）法治疗乳腺钼靶检查发现的乳腺导管原位癌（DCIS）患者的经验，以确定10年局部控制率和生存率，并识别与局部复发相关的因素。
1980年1月至1993年12月，密歇根州皇家橡树市威廉·博蒙特医院对130例患者的132个乳房采用BCT法治疗乳腺钼靶检查发现的DCIS。所有患者均接受了切除活检，64%的患者接受了再次切除。所有患者术后接受全乳照射，中位剂量为45.0戈瑞（Gy）（范围：43.1 - 56.0 Gy）。124例（94%）患者接受了瘤床加量照射，中位总剂量为60.4 Gy（范围：45.0 - 71.8 Gy）。所有病例均由一名病理学家进行完整的病理检查。中位随访时间为7.0年。
在整个研究组中，13例患者同侧乳房出现复发，5年和10年精算复发率分别为8.9%和10.3%。13例复发中有9例（69%）发生在肿块切除腔内或紧邻肿块切除腔，被认定为真性复发或切缘阴性（TR/MM）。4例患者（31%）在乳房其他部位复发。13例复发中有10例（77%）为浸润性，3例（23%）为纯DCIS。仅1例患者死于该病，5年和10年精算特定病因生存率分别为100%和99.0%。分析了多个临床因素、病理因素和治疗相关因素与同侧乳房失败或TR/MM的相关性。多因素分析显示，仅无病理钙化与同侧乳房失败显著相关。在专门分析TR/MM时，诊断时年龄较小、含DCIS的切片数量、切缘5 mm内DCIS和小叶癌变（COL）灶的数量以及无病理钙化显示出统计学显著相关性。切缘接近或阳性状态对TR/MM（P = 0.14）或同侧乳房失败（P = 0.19）均无显著预测价值。
对于采用BCT法治疗乳腺钼靶检查发现的DCIS患者，放疗前充分切除所有DCIS可提高局部控制率。然而，切缘状态可能无法充分预测肿瘤是否完全切除。切缘5 mm内DCIS的体积似乎是切除充分性的更可靠替代指标。此外，年轻患者年龄和无病理钙化是局部复发的独立危险因素。
