Solin L J, Fowble B L, Schultz D J, Goodman R L
Department of Radiation Oncology, University of Pennsylvania School of Medicine, Philadelphia.
Int J Radiat Oncol Biol Phys. 1991 Jul;21(2):279-87. doi: 10.1016/0360-3016(91)90772-v.
To evaluate the significance of the pathology margins of the tumor excision on the outcome of treatment, an analysis was performed of 697 consecutive women with clinical Stage I or II invasive carcinoma of the breast treated with breast-conserving surgery and definitive irradiation. Complete gross excision of the primary tumor was performed in all cases, and an axillary staging procedure was performed to determine pathologic axillary lymph node status. The 697 patients were divided into four groups based on the final pathology margin from the primary tumor excision or from the re-excision if performed. These four groups were: (a) 257 patients with a negative margin (greater than 2 mm), (b) 57 patients with a positive margin, (c) 37 patients with a close margin (less than or equal to 2 mm), and (d) 346 patients with an unknown margin. The patients with positive final pathology margins were focally positive on microscopic examination. Patients with grossly positive margins or with diffusely positive microscopic margins were treated with conversion to mastectomy. There was a significant difference in the total radiation dose for the four groups (median dose of 6000 vs 6500 vs 6400 vs 6240 cGy, respectively; p less than .0001). There was no significant difference among the four groups for 5-year actuarial overall survival (p = .19), no evidence of disease (NED) survival (p = .95), or relapse-free survival (p = .80). There was no significant difference among the four groups for five year actuarial local or regional control (all p greater than or equal to .29). Subset analyses did not identify any poor outcome subgroups. These results have demonstrated that selected patients with focally positive or close microscopic pathology margins can be adequately treated with definitive breast irradiation. Patient selection and the technical delivery of radiation treatment including a boost may have been important contributing factors to the good outcome in these patients.
为评估肿瘤切除的病理切缘对治疗结果的意义，对697例接受保乳手术及根治性放疗的临床Ⅰ期或Ⅱ期浸润性乳腺癌连续病例进行了分析。所有病例均对原发肿瘤进行了完整的大体切除，并进行腋窝分期手术以确定腋窝淋巴结的病理状态。根据原发肿瘤切除或再次切除（若进行了再次切除）后的最终病理切缘，将697例患者分为四组。这四组分别为：(a) 257例切缘阴性（大于2 mm）的患者，(b) 57例切缘阳性的患者，(c) 37例切缘接近（小于或等于2 mm）的患者，以及(d) 346例切缘情况不明的患者。最终病理切缘阳性的患者在显微镜检查时为局灶性阳性。切缘大体阳性或显微镜下弥漫性阳性的患者接受了乳房切除术。四组患者的总放疗剂量存在显著差异（中位剂量分别为6000、6500、6400和6240 cGy；p＜0.0001）。四组患者的5年精算总生存率（p = 0.19）、无疾病证据（NED）生存率（p = 0.95）或无复发生存率（p = 0.80）无显著差异。四组患者的5年精算局部或区域控制率无显著差异（所有p≥0.29）。亚组分析未发现任何预后不良的亚组。这些结果表明，部分切缘局灶性阳性或接近显微镜病理切缘的患者可通过根治性乳房放疗得到充分治疗。患者选择以及包括加量照射在内的放疗技术实施可能是这些患者取得良好预后的重要因素。
