Cody H S
Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA.
Ann Surg. 1997 Apr;225(4):370-6. doi: 10.1097/00000658-199704000-00005.
Is routine contralateral biopsy in the breast cancer patient justified, and by which parameters can the result be predicted in advance?
Routine contralateral biopsy remains controversial, and with the possible exception of an invasive lobular primary, little used by most surgeons. Previous series are biased by small sample size, by interpreting lobular carcinoma in situ (LCIS) as a positive result, by selection on the basis of tumor type, and by the inclusion of patients with clinical or mammographic abnormalities.
Among 1113 consecutive patients with breast cancer treated in the author's practice between 1979 and 1993 (excluding 77 patients who had a previous mastectomy, 131 who declined biopsy, and 34 with suspicious clinical or mammographic findings), 871 had a routine contralateral biopsy.
Invasive cancers were found in 1.6%, duct carcinoma in situ in 1.4%, LCIS in 3.2%, and atypical hyperplasia in 6.9% of all random biopsies. If LCIS was excluded as a positive result, invasive lobular carcinoma was not significantly more bilateral than invasive duct (5.2% vs. 2.9%, p = 0.32), nor were in situ tumors more bilateral than invasive (2.5% vs. 3.0%, p = 0.76). Tumor size, axillary node status, and young age were not predictive of a positive result. A positive biopsy result was significantly more frequent in patients older than 50 years of age (4% vs. 1%, p = 0.016), and with a first-degree family history of breast cancer (6.3% vs. 2.2%, p = 0.004).
The following conclusions can be made: 1. If LCIS was excluded as a positive biopsy result, invasive lobular was not significantly more bilateral than invasive duct cancer. 2. Family history and older age significantly predicted a positive biopsy, whereas young age, tumor size, and axillary node status did not. 3. Routine contralateral biopsy identified conditions (invasive cancer or duct carcinoma in situ) requiring immediate further management in 3.0% of patients, and markers of risk (LCIS or atypia) with the potential to influence future decisions in another 10.1%. 4. As a screening device applied in a high-risk population, with low cost and little morbidity, contralateral biopsy deserves wider consideration in an era of ever-earlier breast cancer diagnosis.
乳腺癌患者进行常规对侧活检是否合理，能否通过哪些参数提前预测结果？
常规对侧活检仍存在争议，除浸润性小叶癌外，大多数外科医生很少使用。既往研究系列存在样本量小、将小叶原位癌（LCIS）解释为阳性结果、基于肿瘤类型进行选择以及纳入有临床或乳腺钼靶异常的患者等偏倚。
在1979年至1993年作者诊治的1113例连续乳腺癌患者中（不包括77例既往接受过乳房切除术的患者、131例拒绝活检的患者以及有可疑临床或乳腺钼靶表现的34例患者），871例进行了常规对侧活检。
在所有随机活检中，浸润性癌的检出率为1.6%，导管原位癌为1.4%，LCIS为3.2%，非典型增生为6.9%。如果将LCIS排除在阳性结果之外，浸润性小叶癌的双侧发生率并不显著高于浸润性导管癌（5.2%对2.9%，p = 0.32），原位肿瘤的双侧发生率也不高于浸润性肿瘤（2.5%对3.0%，p = 0.76）。肿瘤大小、腋窝淋巴结状态和年轻年龄均不能预测阳性结果。活检结果为阳性在年龄大于50岁的患者中更为常见（4%对1%，p = 0.016），且有乳腺癌一级家族史的患者中也更为常见（6.3%对2.2%，p = 0.004）。
可得出以下结论：1. 如果将LCIS排除在阳性活检结果之外，浸润性小叶癌的双侧发生率并不显著高于浸润性导管癌。2. 家族史和高龄显著预测活检结果为阳性，而年轻年龄、肿瘤大小和腋窝淋巴结状态则不能。3. 常规对侧活检在3.0%的患者中发现了需要立即进一步处理的情况（浸润性癌或导管原位癌），并在另外10.1%的患者中发现了可能影响未来决策的风险标志物（LCIS或非典型增生）。4. 作为一种应用于高危人群的筛查手段，对侧活检成本低、发病率低，在乳腺癌诊断日益早期化的时代值得更广泛的考虑。
