Obedian E, Haffty B G
Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut 06520-8040, USA.
Cancer J Sci Am. 2000 Jan-Feb;6(1):28-33.
The purpose of this study was to determine the impact of final pathologic margin status on breast relapse-free survival, distant metastasis-free survival, and overall survival in patients undergoing conservative surgery and radiation therapy for invasive breast cancer.
Between January 1970 and December 1990, 984 patients underwent conservative surgery and radiation therapy at our institution as treatment for invasive breast cancer. After lumpectomy, patients were given radiation therapy to the intact breast with or without treatment to regional nodes with the routine use of electron boost to a total median tumor bed dose of 64 Gy. Pathology reports were available for review in 871 patients. Re-excision was carried out in 294 of these patients. For this analysis, patients were divided into four groups based on final pathologic margin status: negative (n = 278), dose (typically within 2 mm, n = 47), positive (n = 55), or indeterminate (n = 491).
There were no significant differences between the groups with respect to age, histology, estrogen and progesterone receptor status, tumor location, or total radiation dose. Patients with negative margins were more likely than those with positive margins to have T1 mammographically detected lesions, to have negative nodal status, and to have undergone re-excision. Patients with positive margins were more likely to receive adjuvant chemotherapy or hormone therapy (P = 0.001). As of July 1998, with a median follow-up of 13 years, the median breast relapse-free survival, distant metastasis-free survival, and overall survival rates at 10 years for the entire cohort of patients were 86%, 81%, and 76%, respectively. Breast relapse-free survival at 10 years was 98% for patients with negative margins versus 98% for those with close margins versus 83% for those with positive margins versus 82% for those with indeterminate margins. There were no significant differences in breast relapse-free survival between patients with negative and dose margins or between patients with positive and indeterminate margins. Although the negative margin status also conferred an overall survival and distant metastasis-free survival advantage, this difference is confounded by the earlier stage of disease in these patients, and margin status did not influence overall survival in multivariate analysis.
In patients undergoing conservative management of breast cancer, negative margin status significantly improves breast relapse-free survival. Close margins appear equivalent to negative margins, and indeterminate margins appear equivalent to positive margins. Adjuvant chemotherapy or hormone therapy did not counteract the adverse impact of positive margin status. Re-excision to obtain dear surgical margins is recommended, even if a radiation boost or adjuvant systemic therapy is planned.
本研究旨在确定最终病理切缘状态对接受浸润性乳腺癌保乳手术及放疗患者的无乳腺复发生存率、无远处转移生存率和总生存率的影响。
1970年1月至1990年12月期间，984例患者在我院接受保乳手术及放疗以治疗浸润性乳腺癌。肿块切除术后，患者接受全乳放疗，区域淋巴结是否接受治疗不定，常规使用电子束追加剂量，使肿瘤床总中位剂量达到64 Gy。871例患者有病理报告可供查阅。其中294例患者进行了再次切除。基于最终病理切缘状态，将患者分为四组：阴性（n = 278）、近切缘（通常在2 mm以内，n = 47）、阳性（n = 55）或不确定（n = 491）。
各组在年龄、组织学类型、雌激素和孕激素受体状态、肿瘤位置或总放疗剂量方面无显著差异。切缘阴性的患者比切缘阳性的患者更有可能钼靶检查发现T1期病变、淋巴结阴性且接受了再次切除。切缘阳性的患者更有可能接受辅助化疗或激素治疗（P = 0.001）。截至1998年7月，中位随访13年，整个患者队列10年的无乳腺复发生存率、无远处转移生存率和总生存率分别为86%、81%和76%。切缘阴性患者10年无乳腺复发生存率为98%，近切缘患者为98%，切缘阳性患者为83%，切缘不确定患者为82%。切缘阴性与近切缘患者之间以及切缘阳性与切缘不确定患者之间的无乳腺复发生存率无显著差异。虽然切缘阴性状态也带来了总生存和无远处转移生存优势，但这些患者疾病分期较早，使这种差异受到混淆，在多因素分析中切缘状态并未影响总生存。
在接受乳腺癌保乳治疗的患者中，切缘阴性状态显著提高无乳腺复发生存率。近切缘似乎等同于切缘阴性，切缘不确定似乎等同于切缘阳性。辅助化疗或激素治疗并未抵消切缘阳性状态的不利影响。即使计划进行追加放疗或辅助全身治疗，也建议再次切除以获得清晰的手术切缘。
