Merrill Andrea L, Coopey Suzanne B, Tang Rong, McEvoy Maureen P, Specht Michele C, Hughes Kevin S, Gadd Michelle A, Smith Barbara L
Division of Surgical Oncology, Gillette Center for Women's Cancers, Massachusetts General Hospital, Boston, MA, USA.
Division of Breast Surgery, Hunan Cancer Hospital, The Affiliated Tumor Hospital of Xiangya Medical School of Central South University, Changsha, China.
Ann Surg Oncol. 2016 Mar;23(3):729-34. doi: 10.1245/s10434-015-4916-2. Epub 2015 Oct 14.
The 2014 guidelines endorsed by Society of Surgical Oncology, the American Society of Breast Surgeons, and the American Society for Radiation Oncology advocate "no ink on tumor" as the new margin requirement for breast-conserving therapy (BCT). We used our lumpectomy margins database from 2004 to 2006 to predict the effect of these new guidelines on BCT.
Patients with neoadjuvant therapy, pure ductal carcinoma-in situ, or incomplete margin data were excluded. We applied new ("no ink on tumor") and old (≥2 mm) margin guidelines and compared rates of positive margins, reexcision, and rates of residual disease found at reexcision.
A total of 437 lumpectomy surgeries met the eligibility criteria. Eighty-six percent had invasive ductal carcinoma, 12% invasive lobular carcinoma, and 2% invasive ductal carcinoma and invasive lobular carcinoma. Using a ≥2 mm margin standard, 36% of lumpectomies had positive margins compared to 18% using new guidelines (p < 0.0001). Seventy-seven percent of patients with "ink on tumor" had residual disease found at reexcision. Fifty percent of subjects with margins <2 mm had residual disease (p = 0.0013) but would not have undergone reexcision under the new guidelines. With margins of ≥2 mm, residual tumor was seen in the shaved margins of 14% of lumpectomies. Residual tumor was more common in reexcisions for ductal carcinoma-in situ <2 mm from a margin than for invasive cancer (53 vs. 40%), although this was not statistically significant.
Use of new lumpectomy margin guidelines would have reduced reoperation for BCT by half in our patient cohort. However, residual disease was present in many patients who would not have been reexcised with the new guidelines. Long-term follow-up of local recurrence rates is needed to determine if this increase in residual disease is clinically significant.
外科肿瘤学会、美国乳腺外科医师学会和美国放射肿瘤学会认可的2014年指南提倡将“肿瘤无墨水”作为保乳治疗（BCT）新的切缘要求。我们利用2004年至2006年的乳房肿块切除术切缘数据库来预测这些新指南对BCT的影响。
排除接受新辅助治疗、纯导管原位癌或切缘数据不完整的患者。我们应用新的（“肿瘤无墨水”）和旧的（≥2毫米）切缘指南，并比较切缘阳性率、再次切除率以及再次切除时发现的残留疾病率。
共有437例乳房肿块切除术符合纳入标准。86%为浸润性导管癌，12%为浸润性小叶癌，2%为浸润性导管癌和浸润性小叶癌。采用≥2毫米切缘标准时，36%的乳房肿块切除术切缘阳性，而采用新指南时这一比例为18%（p<0.0001）。77%的“肿瘤有墨水”患者在再次切除时发现残留疾病。切缘<2毫米的患者中有50%存在残留疾病（p = 0.0013），但根据新指南这些患者不会接受再次切除。切缘≥2毫米时，14%的乳房肿块切除术的剃除边缘可见残留肿瘤。导管原位癌切缘<2毫米时再次切除的残留肿瘤比浸润性癌更常见（53%对40%），尽管这无统计学意义。
在我们的患者队列中，采用新的乳房肿块切除术切缘指南可使BCT的再次手术率降低一半。然而，许多根据新指南不会接受再次切除的患者仍存在残留疾病。需要对局部复发率进行长期随访，以确定这种残留疾病的增加是否具有临床意义。
