英国曼彻斯特大学Nigel J Bundred团队研究了乳腺癌保乳手术后切缘状态与生存结局的相关性。这一研究成果发表在2022年9月21日出版的《英国医学杂志》上。

为了确定边缘受累是否与远处复发相关，并确定所需边缘，以尽量减少早期浸润性乳腺癌的局部复发和远处复发，研究组在Medline（PubMed）、Embase和Proquest在线数据库中检索文献，未公布的数据来自研究作者，符合资格的试验报告了接受保乳手术的患者（I-III期乳腺癌），允许评估与边缘状态相关的结果，并对患者进行了至少60个月的随访，对这些文献进行系统回顾和荟萃分析。排除仅原位导管癌、新辅助化疗或乳腺切除患者。在适用的情况下，边缘分为墨染肿瘤（涉及）、近边缘（墨染无肿瘤但<2mm）和阴性边缘（≥2mm）。

研究组共纳入1980年1月1日至2021年12月31日的68项研究，包括112140名乳腺癌患者。在所有研究中，9.4%的患者涉及（墨染肿瘤）边缘，17.8%的患者为墨染或接近边缘的肿瘤。墨染肿瘤患者的远处复发率为25.4%，墨染或附近肿瘤患者为8.4%，阴性边缘患者为7.4%。与阴性边缘相比，墨染边缘肿瘤与远处复发（危险比为2.10）和局部复发（1.98）增加相关。在调整接受辅助化疗和放疗后，与阴性边缘相比，近边缘与远处复发（1.38）和局部复发（2.09）增加相关。在2010年以来发表的五项研究中，墨染边缘肿瘤与远处复发（2.41）增加相关，墨染和近边缘肿瘤与阴性边缘相比远处复发（1.44）增加。

研究结果表明，浸润性乳腺癌早期保乳手术后病变边缘受累或较近，与远处复发和局部复发增加相关。外科医生的目标应该是达到至少1毫米的最小净距。根据现有证据，应修订国际准则。

附：原文原文

Title: Margin status and survival outcomes after breast cancer conservation surgery: prospectively registered systematic review and meta-analysis

Author: James R Bundred, Sarah Michael, Beth Stuart, Ramsey I Cutress, Kerri Beckmann, Bernd Holleczek, Jane E Dahlstrom, Jacqui Gath, David Dodwell, Nigel J Bundred

Issue&Volume: 2022/09/21

Abstract:

Objective To determine if margin involvement is associated with distant recurrence and to determine the required margin to minimise both local recurrence and distant recurrence in early stage invasive breast cancer.

Design Prospectively registered systematic review and meta-analysis of literature.

Data sources Medline (PubMed), Embase, and Proquest online databases. Unpublished data were sought from study authors.

Eligibility criteria Eligible studies reported on patients undergoing breast conserving surgery (for stages I-III breast cancer), allowed an estimation of outcomes in relation to margin status, and followed up patients for a minimum of 60 months. Patients with ductal carcinoma in situ only or treated with neoadjuvant chemotherapy or by mastectomy were excluded. Where applicable, margins were categorised as tumour on ink (involved), close margins (no tumour on ink but <2 mm), and negative margins (≥2 mm).

Results 68 studies from 1 January 1980 to 31 December 2021, comprising 112140 patients with breast cancer, were included. Across all studies, 9.4% (95% confidence interval 6.8% to 12.8%) of patients had involved (tumour on ink) margins and 17.8% (13.0% to 23.9%) had tumour on ink or a close margin. The rate of distant recurrence was 25.4% (14.5% to 40.6%) in patients with tumour on ink, 8.4% (4.4% to 15.5%) in patients with tumour on ink or close, and 7.4% (3.9% to 13.6%) in patients with negative margins. Compared with negative margins, tumour on ink margins were associated with increased distant recurrence (hazard ratio 2.10, 95% confidence interval 1.65 to 2.69, P<0.001) and local recurrence (1.98, 1.66 to 2.36, P<0.001). Close margins were associated with increased distant recurrence (1.38, 1.13 to 1.69, P<0.001) and local recurrence (2.09, 1.39 to 3.13, P<0.001) compared with negative margins, after adjusting for receipt of adjuvant chemotherapy and radiotherapy. In five studies published since 2010, tumour on ink margins were associated with increased distant recurrence (2.41, 1.81 to 3.21, P<0.001) as were tumour on ink and close margins (1.44, 1.22 to 1.71, P<0.001) compared with negative margins.

Conclusions Involved or close pathological margins after breast conserving surgery for early stage, invasive breast cancer are associated with increased distant recurrence and local recurrence. Surgeons should aim to achieve a minimum clear margin of at least 1 mm. On the basis of current evidence, international guidelines should be revised.

DOI: 10.1136/bmj-2022-070346

Source: https://www.bmj.com/content/378/bmj-2022-070346