早期采用美国放射肿瘤学会（ASTRO）关于Ⅰ期和Ⅱ期浸润性乳腺癌保乳手术切缘及全乳照射的共识指南：纪念斯隆凯特琳癌症中心的初步经验
Early Adoption of the SSO-ASTRO Consensus Guidelines on Margins for Breast-Conserving Surgery with Whole-Breast Irradiation in Stage I and II Invasive Breast Cancer: Initial Experience from Memorial Sloan Kettering Cancer Center.
作者信息
Rosenberger Laura H, Mamtani Anita, Fuzesi Sarah, Stempel Michelle, Eaton Anne, Morrow Monica, Gemignani Mary L
机构信息
Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
出版信息
Ann Surg Oncol. 2016 Oct;23(10):3239-46. doi: 10.1245/s10434-016-5397-7. Epub 2016 Jul 12.
BACKGROUND
Reexcision rates in patients undergoing breast-conserving surgery (BCS) for early-stage invasive breast cancer are highly variable. The Society of Surgical Oncology (SSO) and American Society for Radiation Oncology (ASTRO) published consensus guidelines to help standardize practice. We sought to determine reexcision rates before and after guideline adoption at our institution.
METHODS
We identified patients with stage I or II invasive breast cancer initially treated with BCS between June 1, 2013, and October 31, 2014. Margins were defined as positive (tumor on ink), close (≤1 mm), or negative (>1 mm), and were recorded for both invasive cancer and ductal carcinoma-in situ (DCIS) components. Reexcision rates were quantified, characteristics were compared between groups, and multivariable logistic regression was performed.
RESULTS
A total of 1205 patients were identified, 504 before and 701 after the guideline adoption (January 1, 2014). Clinical and pathologic characteristics were similar between time periods. Reexcision rates significantly declined from 21.4 to 15.1 % (p = 0.006) after guideline adoption. A multivariable model identified extensive intraductal component (odds ratio [OR] 2.5, 95 % confidence interval [CI] 1.2-5.2), multifocality (OR 2.0, 95 % CI 1.2-3.6), positive (OR 844.4, 95 % CI 226.3-5562.5) and close (OR 38.3, 95 % CI 21.5-71.8) ductal carcinoma-in situ margin, positive (OR 174.2, 95 % CI 66.2-530.0) and close (OR 6.4, 95 % CI 3.0-13.6) invasive margin, and time period (OR 0.5, 95 % CI 0.3-0.9 for post vs. pre) as independently associated with reexcision.
CONCLUSIONS
Overall reexcision rates declined significantly after guideline adoption. Close invasive margins were associated with higher rates of reexcision than negative invasive margins in both time periods; however, the effect diminished in the postguideline adoption period. Thus, we expect continued decline in reexcision rates as adherence to guidelines becomes more uniform.
背景
早期浸润性乳腺癌保乳手术（BCS）患者的再次切除率差异很大。外科肿瘤学会（SSO）和美国放射肿瘤学会（ASTRO）发布了共识指南以帮助规范操作。我们试图确定我院采用指南前后的再次切除率。
方法
我们确定了2013年6月1日至2014年10月31日期间最初接受BCS治疗的I期或II期浸润性乳腺癌患者。切缘定义为阳性（墨线上有肿瘤）、切缘接近（≤1毫米）或阴性（>1毫米），并记录浸润性癌和原位导管癌（DCIS）成分的切缘情况。对再次切除率进行量化，比较组间特征，并进行多变量逻辑回归分析。
结果
共确定1205例患者，其中指南采用前504例，采用后（2014年1月1日）701例。不同时期的临床和病理特征相似。指南采用后，再次切除率从21.4%显著降至15.1%（p = 0.006）。多变量模型确定广泛导管内成分（比值比[OR] 2.5，95%置信区间[CI] 1.2 - 5.2）、多灶性（OR 2.0，95% CI 1.2 - 3.6）、阳性（OR 844.4，95% CI 226.3 - 5562.5）和切缘接近（OR 38.3，95% CI 21.5 - 71.8）的DCIS切缘、阳性（OR 174.2，95% CI 66.2 - 530.0）和切缘接近（OR 6.4，95% CI 3.0 - 13.6）的浸润性切缘以及时期（采用后与采用前相比，OR 0.5，95% CI 0.3 - 0.9）与再次切除独立相关。
结论
指南采用后总体再次切除率显著下降。在两个时期，浸润性切缘接近的再次切除率均高于阴性浸润性切缘；然而，在指南采用后时期，这种影响减弱。因此，随着对指南的遵循更加一致，我们预计再次切除率将持续下降。
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