Monteau Amélie, Sigal-Zafrani Brigitte, Kirova Youlia M, Fourchotte Virginie, Bollet Marc A, Vincent-Salomon Anne, Asselain Bernard, Salmon Remy J, Fourquet Alain
Department of Radiation Oncology, Institut Curie, Paris, France.
Int J Radiat Oncol Biol Phys. 2009 Nov 15;75(4):1021-8. doi: 10.1016/j.ijrobp.2008.12.014. Epub 2009 Apr 20.
Following breast-conserving surgery for DCIS, reexcision before radiotherapy is recommended when margins are close or involved. We investigated whether an additional radiation dose could replace reexcision.
We selected 208 women with DCIS of the breast treated with breast-conserving surgery between 1992 and 2002 who had either close margins (< 2 mm) (89 pts) or focally (< 1 mm) or minimally (1-15 mm) involved margins (119 pts). Sixty-one patients (29%) underwent reexcision before irradiation and 147 patients (71%) received breast irradiation with boost, without reexcision.
Median follow-up was 89 months. Median age was 53 years with 7 patients less than 41. Involved margins were less frequent in the non reexcision group than in the reexcised group (50% vs. 74%, p = 0.0019). All other clinical and histological features were comparable. Median whole-breast radiation dose was 50 Gy. Median total doses to the tumour bed were 67 Gy (range, 45-77) and 60 Gy (range, 46-74), respectively (p < 0.0001). Of the 61 reexcised patients, 56% had residual DCIS and 6% had invasive cancer. Six underwent a mastectomy for persistent margin involvement. Seven-year locoregional failure rates were 9.3% without, and 9.6% with reexcision (ns). No differences were observed when adjusting for margin status.
In carefully selected patients with close (< 2 mm) or focally/minimally involved margins, reexcision may be avoided and satisfactory local control achieved by increasing the radiation dose to the tumour bed to at least 66 Gy. These results only apply to patients older than 40 and would need confirmation in independent series.
对于接受保乳手术治疗的导管原位癌（DCIS）患者，当切缘接近或受累时，建议在放疗前进行再次切除。我们研究了增加额外的放射剂量是否可以替代再次切除。
我们选择了1992年至2002年间接受保乳手术治疗的208例乳腺DCIS女性患者，这些患者的切缘接近（<2mm）（89例）或局部（<1mm）或轻微（1 - 15mm）受累（119例）。61例患者（29%）在放疗前接受了再次切除，147例患者（71%）接受了加量乳腺照射，未进行再次切除。
中位随访时间为89个月。中位年龄为53岁，7例患者年龄小于41岁。未进行再次切除组的受累切缘发生率低于再次切除组（50%对74%，p = 0.0019）。所有其他临床和组织学特征具有可比性。全乳中位放射剂量为50Gy。肿瘤床的中位总剂量分别为67Gy（范围45 - 77）和60Gy（范围46 - 74）（p < 0.0001）。在61例接受再次切除的患者中，56%有残留DCIS，6%有浸润性癌。6例因切缘持续受累接受了乳房切除术。未进行再次切除和进行再次切除的患者7年局部区域失败率分别为9.3%和9.6%（无统计学差异）。调整切缘状态后未观察到差异。
在精心选择的切缘接近（<2mm）或局部/轻微受累的患者中，可以避免再次切除，通过将肿瘤床的放射剂量增加至至少66Gy可实现满意的局部控制。这些结果仅适用于年龄大于40岁的患者，需要在独立系列研究中得到证实。
