Neuschatz Andrew C, DiPetrillo Thomas, Safaii Homa, Price Lori Lyn, Schmidt-Ullrich Rupert K, Wazer David E
Department of Radiation Oncology #359, Tufts-New England Medical Center, Boston, MA 02111, USA.
Cancer. 2003 Jan 1;97(1):30-9. doi: 10.1002/cncr.10981.
A prospectively applied treatment policy for breast-conserving therapy used margin assessment as the exclusive guide to the intensity of radiation therapy directed at the tumor bed.
From 1982 to 1994, 498 women with 509 Stage I/II breast carcinomas with a median follow-up of 121 months were treated. Final margin status (FMS) categories were defined as greater than 5 mm, greater than 2-5 mm, greater than 0-2 mm, and positive. For margins less than or equal to 2 mm or indeterminate, reexcisions were performed if feasible. All patients received whole breast irradiation to 50.0-50.4 Gy. Final tumor bed boosts as a function of FMS were as follows: no residual on reexcision, no boost performed; FMS greater than 5 mm, boost of 10 Gy; FMS greater than 2-5 mm, boost of 14 Gy; FMS greater than 0-2 mm or positive, boost of 20 Gy. Cases were analyzed for local failure with respect to histology, age, tumor size, excision volume, reexcision, and total dose.
FMS was positive, greater than 0-2 mm, greater than 2-5 mm, and greater than 5 mm, and no residual tumor on reexcision in 21%, 20%, 17%, 14%, and 28% of cases, respectively. At 12 years, Kaplan-Meier local failure rates were 17% for FMS positive, 9% for FMS greater than 0-2 mm, 5% for FMS greater than 2-5 mm, 0% for FMS greater than 5 mm, and 6% for specimens without evidence of residuum on reexcision (P = 0.009). Patients 45 years old and younger had a 12-year local failure rate of 15% whereas patients older than 45 years had a 12-year local failure rate of 6% (P = 0.01). On multivariate analysis, young age (P = 0.03) predicted increased local failure rate, whereas margins that were less than or equal to 2 mm or positive predicted late (> 5 years) but not early (< or = 5 years) recurrence (P = 0.003).
Graded tumor bed dose escalation in response to FMS results in very low rates of local failure over the first 5 years for all FMS categories. However, tumors with close/positive margins have significantly increased local failure rates after 5 years of follow-up even with increased radiation boost dose. In addition, graded tumor bed dose escalation does not fully overcome the adverse influence of young age.
一种前瞻性应用的保乳治疗策略将切缘评估作为针对瘤床的放射治疗强度的唯一指导。
1982年至1994年，对498例患有509例I/II期乳腺癌的女性进行了治疗，中位随访时间为121个月。最终切缘状态（FMS）类别定义为大于5毫米、大于2 - 5毫米、大于0 - 2毫米和阳性。对于切缘小于或等于2毫米或不确定的情况，若可行则进行再次切除。所有患者均接受全乳照射，剂量为50.0 - 50.4 Gy。根据FMS对最终瘤床加量如下：再次切除无残留，不进行加量；FMS大于5毫米，加量10 Gy；FMS大于2 - 5毫米，加量14 Gy；FMS大于0 - 2毫米或阳性，加量20 Gy。分析病例的局部复发情况，涉及组织学、年龄、肿瘤大小、切除体积、再次切除和总剂量。
FMS为阳性、大于0 - 2毫米、大于2 - 5毫米、大于5毫米以及再次切除无残留肿瘤的病例分别占21%、20%、17%、14%和28%。12年时，FMS为阳性的患者的Kaplan - Meier局部复发率为17%，FMS大于0 - 2毫米的为9%，FMS大于2 - 5毫米的为5%，FMS大于5毫米的为0%，再次切除无残留证据的标本为6%（P = 0.009）。45岁及以下患者的12年局部复发率为15%，而45岁以上患者的12年局部复发率为6%（P = 0.01）。多因素分析显示，年轻（P = 0.03）预示局部复发率增加，而切缘小于或等于2毫米或阳性预示晚期（> 5年）而非早期（≤ 5年）复发（P = 0.003）。
根据FMS进行分级瘤床剂量递增导致所有FMS类别在最初5年的局部复发率非常低。然而，切缘接近/阳性的肿瘤在随访5年后局部复发率显著增加，即使增加了放射加量剂量。此外，分级瘤床剂量递增并不能完全克服年轻的不利影响。
