乳腺癌术前化疗后保乳手术的切缘
由于2014年美国保乳手术切缘共识指南将术前新辅助化疗患者排除在外，故术前新辅助化疗后保乳手术的最佳切缘宽度尚不明确。
2018年8月20日，美国乳腺外科医师学会和肿瘤外科学会《肿瘤外科年鉴》在线发表哈佛大学医学院布列根妇女医院、达纳法伯布列根妇女癌症中心、达纳法伯癌症研究所、韩国岭南大学医学院、加拿大卡尔加里大学的研究报告，探讨了切缘宽度对术前新辅助化疗＋保乳疗法后局部复发和生存的影响。
该研究根据哈佛大学医学院布列根妇女医院数据库，对2002～2014年接受新辅助化疗＋保乳疗法（保乳手术＋全乳放疗）的I～III期乳腺癌患者进行多因素风险比例回归模型分析，确定切缘宽度对无局部复发生存、无病生存、总生存的影响。
结果发现，符合分析条件的患者共计382例：
随访：中位57个月（范围10～148个月）
年龄：中位51岁（范围22～79岁）
肿瘤大小：中位3.0cm（范围0.6～11.0cm）
激素受体阴性HER2阴性：144例（37.7%）
激素受体阴性HER2阳性：47例（12.3%）
激素受体阳性HER2阴性：118例（30.9%）
激素受体阳性HER2阳性：70例（18.3%）
乳腺病理完全缓解：105例（27.5%）
最终切缘阳性：8例（2.1%）
最终切缘≤1mm：65例（17.0%）
最终切缘1.1～2mm：30例（7.9%）
最终切缘>2mm：174例（45.5%）
5年无局部复发生存：96.3%（95%置信区间：94.0～98.6）
5年无病生存：85.5%（95%置信区间：81.8～90.7）
5年总生存：90.8%（95%置信区间：87.4～94.2）
最终切缘≤2与>2mm相比、≤1与>1mm相比，无局部复发生存、无病生存、总生存相似。激素受体阳性（P=0.04）和病理完全缓解（P=0.03）有利于无病生存，淋巴结阴性（P<0.001）有利于无病生存和总生存。
因此，该研究结果表明，对此接受新辅助化疗＋保乳疗法治疗的患者队列，切缘宽度对无局部复发生存、无病生存、总生存无影响。虽然有必要进一步研究，但是新辅助化疗后切缘较小（≤2mm）患者的长期结局良好，表明对于经过适当筛选的患者，切缘“肿瘤无墨染”可以被接受。
Ann Surg Oncol. 2018 Aug 20. [Epub ahead of print]
Margins in Breast-Conserving Surgery After Neoadjuvant Therapy.
Jungeun Choi, Alison Laws, Jiani Hu, William Barry, Mehra Golshan, Tari King.
Yeungnam University College of Medicine, Gyeongsan, Korea; Brigham and Women's Hospital, Boston, USA; Dana-Farber/Brigham and Women's Cancer Center, Boston, USA; University of Calgary, Calgary, Canada; Dana-Farber Cancer Institute, Boston, USA.
BACKGROUND: Optimal margin width for breast-conserving therapy (BCT) after neoadjuvant chemotherapy (NAC) is unknown. We sought to determine the impact of margin width on local recurrence and survival after NAC and BCT.
METHODS: Patients treated with NAC and BCT for stage I-III breast cancer from 2002 to 2014 were identified. Multivariate Cox regression was performed to determine the relationship between margin width and local recurrence free-survival (LRFS), disease-free survival (DFS), and overall survival (OS).
RESULTS: A total of 382 patients were included. Median age was 51 years [range 22-79], median tumor size 3.0 cm [range 0.6-11.0], and receptor subtypes included 144 (37.7%) HR-/HER2-, 47 (12.3%) HR-/HER2+, 118 (30.9%) HR+/HER2-, and 70 (18.3%) HR+/HER2+. Breast pathologic complete response (pCR) was achieved in 105 (27.5%) patients. Final margin status was positive in 8 (2.1%) patients, ≤1 mm in 65 (17.0%), 1.1-2 mm in 30 (7.9%), and>2 mm in 174 (45.5%). The 5-year LRFS was 96.3% (95% CI 94.0-98.6), DFS was 85.5% (95% CI 81.8-90.7), and OS was 90.8% (95% CI 87.4-94.2). There was no difference in LRFS, DFS, or OS for margins≤2 versus>2 mm, and no difference in DFS or OS for margins≤1 versus>1 mm. HR+ subtype (p=0.04) and pCR (p=0.03) were correlated with favorable DFS and node negativity (p<0.001) with favorable DFS and OS.
CONCLUSIONS: In this cohort treated with NAC and BCT, there was no association between margin width and LRFS, DFS, or OS. Although further studies are needed, the excellent long-term outcomes demonstrated in patients with close (≤2 mm) margins following NAC suggest that a margin of "no-ink-on-tumor" may be acceptable in appropriately selected patients.
DOI: 10.1245/s10434-018-6702-4
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