Lynn Sage Comprehensive Breast Center and Department ofSurgery, Feinberg School of Medicine of Northwestern University, Chicago, Illinois 60614, USA.
Oncology (Williston Park). 2011 Sep;25(10):890-5.
Adequate surgical margins in breast-conserving surgery are an important predictor of local recurrence (LR) rates. The definition of tumor-free margins in National Surgical Adjuvant Breast and Bowel Project (NSABP) trials requires that tumor cells do not touch ink, but subsequent retrospective single-institution studies have suggested that wider margins confer greater protection against LR. Particularly wide margins have been proposed for ductal carcinoma in situ. However, wider margin requirements lead to higher re-excision rates, with attendant economic, psychological, and cosmetic costs, and perhaps increased mastectomy rates. Juxtaposed against these concerns about optimal margin width, a meta-analysis of clinical trials has demonstrated the survival value of minimizing LR. We are therefore at a juncture where a reduction of LR may be achieved by tumor resection with wide margins, but data regarding optimal margin width are conflicting and the risk/benefit balance of tumorectomy with wide margins has not been demonstrated. A randomized trial of reexcision for close margins inserted into trials of systemic therapy could be considered but seems unlikely. Alternatively, detailed longitudinal data need to balance the value and the cost of wide margins. Until better data are available, the desirable margin width will vary depending on individual circumstances, including age, histology, and patient preference.
保乳手术中的充分手术切缘是局部复发 (LR) 率的一个重要预测因素。国家外科辅助乳腺和肠道项目 (NSABP) 试验中肿瘤无切缘的定义要求肿瘤细胞不能接触墨，但随后的回顾性单机构研究表明，更宽的切缘提供了对 LR 更大的保护。特别是宽的切缘已被提议用于导管原位癌。然而，更宽的切缘要求导致更高的再次切除率，随之而来的是经济、心理和美容方面的成本，以及可能增加的乳房切除术率。在考虑这些关于最佳切缘宽度的担忧的同时，临床试验的荟萃分析证明了最小化 LR 的生存价值。因此，我们正处于一个通过广泛切缘的肿瘤切除术来降低 LR 的关键时刻，但关于最佳切缘宽度的数据存在冲突，广泛切缘的肿瘤切除术的风险/获益平衡尚未得到证明。在系统治疗试验中插入密切切缘的再次切除术随机试验可以考虑，但似乎不太可能。或者，需要详细的纵向数据来平衡广泛切缘的价值和成本。在更好的数据可用之前，理想的切缘宽度将根据个体情况而有所不同，包括年龄、组织学和患者偏好。
