保乳术后同侧复发再次肿块切除术

　　对于保乳术后同侧乳腺肿瘤复发患者，再次肿块切除术的获益尚不明确。

　　2019年3月6日，美国转化肿瘤学会《肿瘤学家》在线发表复旦大学附属肿瘤医院苏永辉、郭瑢、薛静彦、迟亚云、杨犇龙、吴炅等学者的研究报告，发现单纯肿块切除术可能增加同侧乳腺肿瘤复发的死亡率。

　　该人群大数据回顾研究通过监测流行病学最终结果（SEER）登记数据库获取1973～2013年同侧乳腺肿瘤复发最终手术患者数据，通过多因素比例风险回归模型和分层倾向评分匹配法，定量分析同侧乳腺肿瘤复发不同手术方式对所有原因死亡和癌症所致死亡的影响。

　　结果，同侧乳腺肿瘤复发患者5098例，其中乳房切除术4048例（79.4%）、肿块切除术1050例（20.1%）。

　　根据多因素比例风险回归模型分析，肿块切除术与乳房切除术相比：

• 所有原因致死风险增加52.2%（风险比：1.522，95%置信区间：1.317～1.759，P<0.001）

• 癌症所致死亡风险增加66.6%（风险比：1.666，95%置信区间：1.319～2.105，P<0.001）

　　根据分层倾向评分匹配法队列分析，肿块切除术与乳房切除术相比：

• 所有原因致死风险增加50.5%（风险比：1.505，95%置信区间：1.233～1.838，P<0.001）

• 癌症所致死亡风险增加78.7%（风险比：1.787，95%置信区间：1.25 ～2.555，P=0.001）

　　不过，肿块切除术＋放疗与乳房切除术相比，所有原因致死风险相似。此外，同侧乳腺肿瘤复发较小（≤1厘米）肿块切除术＋放疗与乳房切除术相比，所有原因致死风险和癌症所致死亡风险相似。

　　因此，该真实世界观察研究结果表明，对于保乳术后同侧乳腺肿瘤复发患者，肿块切除术与乳房切除术相比，所有原因致死风险和癌症所致死亡风险较高。此外，肿块切除术＋放疗与乳房切除术相比，所有原因致死风险相似，如果肿瘤较小，癌症所致死亡风险也相似，此类肿瘤较小（≤1厘米）患者可能比较适合肿块切除术＋放疗，以避免创伤较大的乳房切除术。

Oncologist. 2019 Mar 6. [Epub ahead of print]

Increased Mortality with Repeat Lumpectomy Alone After Ipsilateral Breast Tumor Recurrence.

Su Y, Guo R, Xue J, Chi Y, Chi W, Wang J, Yang B, Wu J.

Fudan University Shanghai Cancer Center, Shanghai, China; Shanghai Medical College, Fudan University, Shanghai, China.

BACKGROUND: The benefit of repeat lumpectomy for ipsilateral breast tumor recurrence (IBTR) after breast conserving surgery is currently inconclusive.

MATERIALS AND METHODS: Patients with IBTR with definitive surgery were identified in the Surveillance, Epidemiology, and End Results registry between 1973 and 2013. The effect of different IBTR surgeries on overall and cancer-specific mortality was assessed using risk-adjusted Cox proportional hazard regression modeling and stratified propensity score-matching analysis (PSMA).

RESULTS: Of the 5,098 patients with IBTR, 4,048 (79.4%) women underwent mastectomy and 1,050 (20.1%) underwent repeat lumpectomy. In multivariable Cox regression analysis, repeat lumpectomy was associated with increased overall mortality (hazard ratio for death [HR], 1.522; 95% confidence interval [CI], 1.317-1.759; p < 0.001) and cancer-specific mortality (HR, 1.666; 95% CI, 1.319-2.105; p < 0.001). Similar HRs were derived from the PSMA cohort. However, we found no significant difference in overall mortality for women who underwent repeat lumpectomy followed by radiation therapy (RT) compared with that for those who underwent mastectomy. Moreover, patients with IBTR with small tumors (≤1 cm) who underwent repeat lumpectomy with RT rather than without had similar overall and cancer-specific survival rates to those who underwent mastectomy.

CONCLUSION: Our investigation suggests that compared with mastectomy, repeat lumpectomy for IBTR is associated with higher overall and cancer-specific mortality under real-world observational conditions. Furthermore, repeat lumpectomy with RT is equivalent to mastectomy with respect to overall mortality and may influence treatment decision making for patients with small IBTR.

IMPLICATIONS FOR PRACTICE: Although mastectomy has been regarded as the standard treatment for ipsilateral breast tumor recurrence (IBTR) after breast conserving surgery, many patients diagnosed with small and early-detected recurrent tumor might be technically suitable for a less invasive surgical procedure. However, different studies have drawn inconsistent conclusions. The present study is a population-based analysis, which demonstrated the overall unfavorable impact of repeat lumpectomy over mastectomy on survival outcomes for patients with IBTR. However, patients with small IBTR (≤1 cm) that can tolerate radiation therapy may be the optimal candidates for repeat lumpectomy.

KEYWORDS: Breast cancer The Surveillance, Epidemiology, and End Results (SEER) database Ipsilateral recurrence Surgery Radiation therapy

DOI: 10.1634/theoncologist.2018-0606