Vos Elvira L, Siesling Sabine, Baaijens Margreet H A, Verhoef Cornelis, Jager Agnes, Voogd Adri C, Koppert Linetta B
Department of Oncological Surgery, Erasmus MC Cancer Institute, DHA-102, PO Box 2400, 3000, Rotterdam, The Netherlands.
Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), PO Box 19079, 3501, Utrecht, The Netherlands.
Breast Cancer Res Treat. 2017 Jul;164(1):157-167. doi: 10.1007/s10549-017-4232-6. Epub 2017 Apr 7.
In contrast to other countries, the Dutch breast cancer guideline does not recommend re-excision for focally positive margins after breast-conserving surgery (BCS) in invasive tumor and does recommend whole-breast irradiation including boost. We investigated whether omitting re-excision as compared to performing re-excision affects prognosis with a retrospective population-based cohort study.
The total cohort included 32,119 women with primary BCS for T1-T3 breast cancer diagnosed between 2003 and 2008 from the nationwide Netherlands cancer registry. The subcohort included 10,433 patients in whom the resection margins were registered. Outcome measures were 5-year ipsilateral breast tumor recurrence (IBTR) rate, 5-year disease-free survival (DFS) rate, and 10-year overall survival (OS) rate.
In the total cohort, 25,878 (80.6%) did not have re-excision, 2368 (7.4%) had re-excision by BCS, and 3873 (12.1%) had re-excision by mastectomy. Five-year IBTR rates were 2.1, 2.8, and 2.9%, respectively (p = 0.001). In the subcohort, 7820 (75.0%) had negative margins without re-excision, 492 (4.7%) had focally positive margins without re-excision, 586 (5.6%) had focally positive margins and underwent re-excision, and 1535 (14.7%) had extensively positive margins and underwent re-excision. Five-year IBTR rate was 2.3, 2.9, 1.1, and 2.9%, respectively (p = 0.099). Compared to omitting re-excision, performing re-excision for focally positive margins was associated with lower risk of IBTR (adjusted HR 0.30, 95% CI 0.11-0.82), but not with DFS (adjusted HR 0.83 95% CI 0.59-1.17) nor with OS (adjusted HR 1.17 95% CI 0.87-1.59).
Omitting re-excision in breast cancer patients for focally positive margins after BCS does not impair DFS and OS, provided that whole-breast irradiation including boost is given.
与其他国家不同，荷兰乳腺癌指南不建议对浸润性肿瘤保乳手术后切缘局部阳性的患者进行再次切除，而是建议进行包括瘤床加量的全乳照射。我们通过一项基于人群的回顾性队列研究，调查了与进行再次切除相比，省略再次切除是否会影响预后。
整个队列包括2003年至2008年间从荷兰全国癌症登记处确诊为T1 - T3期乳腺癌并接受保乳手术的32119名女性。亚队列包括10433名记录了切缘情况的患者。观察指标为5年同侧乳腺肿瘤复发（IBTR）率、5年无病生存率（DFS）和10年总生存率（OS）。
在整个队列中，25878名（80.6%）未进行再次切除，2368名（7.4%）通过保乳手术进行了再次切除，3873名（12.1%）通过乳房切除术进行了再次切除。5年IBTR率分别为2.1%、2.8%和2.9%（p = 0.001）。在亚队列中，7820名（75.0%）切缘阴性未进行再次切除，492名（4.7%）切缘局部阳性未进行再次切除，586名（5.6%）切缘局部阳性并进行了再次切除，1535名（14.7%）切缘广泛阳性并进行了再次切除。5年IBTR率分别为2.3%、2.9%、1.1%和2.9%（p = 0.099）。与省略再次切除相比，对切缘局部阳性进行再次切除与较低的IBTR风险相关（校正风险比0.30，95%可信区间0.11 - 0.82），但与DFS无关（校正风险比0.83，95%可信区间0.59 - 1.17），也与OS无关（校正风险比1.17，95%可信区间0.87 - 1.59）。
对于保乳手术后切缘局部阳性的乳腺癌患者，若进行包括瘤床加量的全乳照射，省略再次切除不会损害DFS和OS。
