早期浸润性乳腺癌患者保乳手术的再手术率差异很大。因此，美国外科肿瘤学会（SSO）和美国放射肿瘤学会（ASTRO）于2014年发表Ⅰ、Ⅱ期浸润性乳腺癌保乳手术切缘及全乳放疗共识指南，以帮助临床实践标准化。
2016年7月12日，SSO和美国乳腺外科医师学会官方期刊《外科肿瘤学年鉴》在线发表纪念斯隆-凯特林癌症中心（纽约肿瘤医院）的初步经验报告，分析了早期实施该指南前后的再手术率变化。
该研究分析了2013年6月1日～2014年10月31日行保乳手术的1205例Ⅰ或Ⅱ浸润性乳腺癌患者，指南实施（2014年1月1日）前后分别为504例、701例。切缘定义为阳性（肿瘤墨染）、接近（≤1mm）或阴性（＞1mm），包括浸润性癌和导管原位癌成分。
结果发现，指南实施前后的临床及病理特征相似，再手术率从21.4%显著降至15.1%（P=0.006）。多变量模型确定以下因素与再手术率独立相关：广泛导管内癌成分（比值比：2.5，95%置信区间：1.2～5.2）、多发病灶（比值比：2.0，95%置信区间：1.2～3.6）、切缘导管原位癌阳性（比值比：844.4，95%置信区间：226.3～5562.5）和接近（比值比：38.3，95%置信区间：21.5～71.8）、切缘浸润性癌阳性（比值比：174.2，95%置信区间：66.2～530.0）和接近（比值比：6.4，95%置信区间：3.0～13.6）、时间段（指南实施后、前，比值比：0.5，95%置信区间：0.3～0.9）。
因此，指南实施后总体再手术率显著下降。切缘与浸润性癌≤1mm与＞1mm相比，指南实施前后的再手术率均较高；然而，该影响在指南实施后有所减弱。随着对指南的依从性更统一，预计再手术率继续下降。
纪念斯隆-凯特林癌症中心前身为纽约肿瘤医院，成立于1884年。1934～1939年在约翰·戴维森·洛克菲勒的捐助下迁址扩建并更名为纪念医院，1945年在通用汽车总裁兼董事长艾尔弗雷德·斯隆和研发副总裁查尔斯·凯特林的捐助下成立斯隆-凯特林研究所，1980年纪念医院与斯隆-凯特林研究所正式合并改为现名，成为世界上历史最悠久、规模最大的私立癌症中心，目前是美国排名仅次于德克萨斯大学MD安德森癌症中心的肿瘤医院。
Ann Surg Oncol. 2016 Jul 12. [Epub ahead of print]
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.
Rosenberger LH, Mamtani A, Fuzesi S, Stempel M, Eaton A, Morrow M, Gemignani ML.
Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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.
PMID: 27411549
DOI: 10.1245/s10434-016-5397-7
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