Department of Histopathology, Division of Cancer and Stem Cells, School of Medicine, The University of Nottingham, Nottingham City Hospital, Nottingham, UK.
Department of Research Oncology, King's College London, Guy's Hospital, London, UK.
Histopathology. 2017 Apr;70(5):681-692. doi: 10.1111/his.13116. Epub 2016 Dec 20.
The introduction of mammographic screening has resulted in a rise in the detection rate of ductal carcinoma in situ (DCIS), currently accounting for one-fifth of screen-detected breast cancers. Although 60-70% of DCIS are treated with breast-conserving surgery (BCS) with or without radiotherapy, the frequency of subsequent surgery to re-excise positive margins in order to reduce the probability of recurrences remains high. DCIS recurrence is associated not only with financial, health and psychological implications; approximately half these recurrences are invasive disease. An appropriate margin width for patients undergoing BCS for invasive breast cancer has been largely agreed. Although there is a perception that such recommendations may be applicable to DCIS, major differences exist which may affect this application. Importantly, DCIS patients often do not receive systemic adjuvant (endocrine) therapy and not all receive radiotherapy in routine practice. There is evidence that wide margins (i.e. >10 mm) confer better protection against recurrence than positive (i.e. 0 mm) margins; however, there remains a debate concerning the optimum margin width between 0 and 10 mm. Previous studies have demonstrated that radiation therapy may not compensate for lack of re-excision in those patients with positive or close margins, while wide margins will inevitably compromise cosmesis and patients' body image perception. This review aims to address the clinical question of the minimal margin width in DCIS treated with BCS that is associated with the lowest recurrence rate and when, therefore, further surgical intervention for re-excision can be safely avoided. A range of clinical circumstances that might affect this are considered.
乳腺 X 线筛查的引入导致导管原位癌（DCIS）的检出率上升，目前约占筛查发现乳腺癌的五分之一。虽然 60-70%的 DCIS 采用保乳手术（BCS）治疗，无论是否联合放疗，但为降低复发概率而再次切除阳性切缘的手术频率仍然很高。DCIS 复发不仅与经济、健康和心理影响有关；大约一半的这些复发是侵袭性疾病。接受保乳手术治疗浸润性乳腺癌的患者的适当切缘宽度已基本达成共识。尽管人们认为这些建议可能适用于 DCIS，但存在一些可能影响这种应用的重大差异。重要的是，DCIS 患者通常不接受系统辅助（内分泌）治疗，并非所有患者在常规实践中都接受放疗。有证据表明，宽切缘（即>10mm）比阳性切缘（即 0mm）更能预防复发；然而，在 0 至 10mm 之间的最佳切缘宽度仍存在争议。先前的研究表明，对于阳性或接近切缘的患者，放疗可能无法弥补未再次切除的缺陷，而宽切缘不可避免地会影响美容效果和患者的身体形象感知。本综述旨在探讨 BCS 治疗 DCIS 时与最低复发率相关的最小切缘宽度，并确定何时可以安全避免进一步的手术干预以再次切除。还考虑了可能影响这一问题的一系列临床情况。
