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1.
Cellini C Huston TL Martins D Christos P Carson J Kemper S Simmons RM 《American journal of surgery》2005,189(6):662-666
BACKGROUND: Persistently involved margins following breast conservation surgery (BCS) create a diagnostic dilemma regarding the recommendation of further BCS or mastectomy. METHODS: A retrospective review of 276 breast cancer patients who underwent BCS and required additional surgical treatment between 1990-2002 was performed. RESULTS: For treatment of persistently involved margins, 63% of subjects underwent re-excision the first time, 49% the second time, and 37% the third time. The incidence of residual carcinoma increased linearly with the number of initially involved margins (P = .03). Ductal carcinoma-in-situ (DCIS) or infiltrating lobular carcinoma (IFLC) primary histology was associated with a higher rate of residual cancer compared to invasive ductal carcinoma (IFDC) (62% vs. 69% vs. 54%, respectively, P = .56). A trend towards an increased risk of residual cancer in primary tumors > or =2 cm versus tumors under 2 cm was also evident (63%% vs. 50%, respectively, P = .38). CONCLUSIONS: Approximately half of patients repeatedly selected BCS over mastectomy. It is important to realistically discuss the probability of definitive resection with patients who are undergoing breast conservation with re-excision. 相似文献
2.
Menes TS Tartter PI Bleiweiss I Godbold JH Estabrook A Smith SR 《Annals of surgical oncology》2005,12(11):881-885
Background Microscopically clear lumpectomy margins are critical for optimizing local control with breast conservation for cancer. Re-excisions
are often necessary to achieve clear surgical margins. Factors that contribute to nonnegative margins and necessitate re-excision
may increase the risk of local recurrence.
Methods Patients who were treated with breast conservation for breast cancers were identified from a prospective database maintained
by one of the authors. Factors associated with local recurrence were evaluated in 459 consecutive patients with attention
to the number of re-excisions required to obtain clear margins.
Results Twenty-eight patients (5%) developed local recurrences at a mean follow-up of 78 months. In multivariate analysis, local recurrence
was most significantly associated with the omission of radiotherapy (19% vs. 5%; relative risk [RR], 3.64; 95% confidence
interval, 1.6–8.2), followed by young age (52 vs. 58; 95% confidence interval, −.83 to −10.6 years) and the number of re-excisions
required to obtain clear margins (none, 4%; one, 7% [RR, 2.05; 95% confidence interval, .86–4.89]; two or more, 17% [RR, 5.20;
95% confidence interval, 1.44–18.8]). Tumor size, the number of involved nodes, pathology, and adjuvant chemotherapy were
not significantly related to local recurrence.
Conclusions The risk of local recurrence after breast conservation for breast cancer increases progressively with the number of re-excisions
needed to achieve clear margins. Patients in whom the cancer is fully excised with clear margins in the first excision will
have less of a chance of local recurrence compared with patients who need further re-excision to achieve clear margins. 相似文献
3.
Carla J. Christy MD David Thorsteinsson MD Baiba J. Grube MD MS Dalliah Black MD Maysa Abu-Khalaf MD Gina G. Chung MD Michael P. DiGiovanna MD PhD Kenneth Miller MD Susan A. Higgins MD Joanne Weidhaas MD PhD Lyndsay Harris MD Fattaneh A. Tavassoli MD Donald R. Lannin MD 《Annals of surgical oncology》2009,16(3):697-702
Introduction It is accepted that preoperative chemotherapy can result in increased breast preservation for breast cancers greater than
4 cm. The benefits of preoperative chemotherapy are less clear, however, for patients who present with smaller tumors and
are already candidates for breast-preserving surgery. The goal of this study is to assess the effect of preoperative chemotherapy
on breast cancers between 2 and 4 cm diameter.
Methods A retrospective chart review was conducted of patients diagnosed with new breast cancer at the Yale-New Haven Breast Center
for the years 2002–2007. Patients were included in the study if their breast cancer was between 2 and 4 cm and their initial
surgical treatment had been completed. Patients with distant metastases were excluded.
Results There were 156 new cancers that met study requirements. Forty-seven patients underwent preoperative chemotherapy, and 109
patients had their surgery first, usually followed by chemotherapy. Initial surgery was lumpectomy for 31 out of 47 patients
(66%) in the preoperative chemotherapy group compared with 62 out of 109 patients (57%) in the surgery group. For patients
with lumpectomies, 2 out of 31 patients (6%) in the preoperative group had positive margins and required re-excision compared
with 20 out of 62 patients (37%) in the surgery-first group (P < 0.01).
Conclusions We conclude that, for tumors between 2 and 4 cm, preoperative chemotherapy is associated with a significantly decreased rate
of re-excision following lumpectomy. This not only results in fewer mastectomies, but also avoids the morbidity and inferior
cosmetic results associated with a re-excision lumpectomy.
Presented at the 61st Meeting of the Society of Surgical Oncology, March 13–16, 2008, Chicago, IL.
Carla J. Christy is a Norma Lies Mitchell Interdisciplinary Breast Fellow funded by the Breast Cancer Alliance, Greenwich,
CT. 相似文献
4.
Purpose To evaluate the impact of preoperative diagnosis in obtaining negative lumpectomy margins.
Materials and Methods Five hundred and thirty five patients who underwent breast conserving therapy for stage I/II cancer from 1971 to 1996 were
included in this IRB-approved retrospective analysis. Three hundred and ninety five patients had a defined inked margin status
after initial excision. The following factors were evaluated for correlation with margins at initial excision: age (< or >45),
grade (3/1 or 2), family history (present/absent), histology (lobular/other), estrogen receptor (ER) status, presence of extensive
intraductal carcinoma (EIC), presence of lymphovascular invasion (LVI), and biopsy type (excisional/preoperative).
Results Biopsy type (P < 0.0001), EIC (P = 0.002), ER status (P = 0.02), lobular histology (P = 0.02) and age (P = 0.02) were significantly correlated with initial margin status among the entire group. For patients who underwent preoperative
diagnostic biopsy, 52% (35/67) had negative initial margins as compared to 29% (94/328) for excisional biopsy. Among patients
who underwent preoperative biopsy, only lobular histology (P = 0.04) and LVI (P = 0.04) were related to initial margin status. The rate of re-excision was 34% for patients diagnosed preoperatively versus
61% with excisional biopsy (P < 0.0001). The percentage of patients with negative final margin status was similar with either core/needle or excisional
biopsy (79 and 78%, respectively).
Conclusions Preoperative diagnosis is the most significant predictor of initial margin status in patients undergoing breast conservation.
Patients with lobular histology may require improved preoperative and/or intraoperative assessment to increase the rate of
negative margins at initial excision. 相似文献
5.
Background Little is known about breast cancer management among Asian Americans and Pacific Islanders (AAPI).
Methods We performed a retrospective analysis of 2030 women (935 Japanese, 144 Chinese, 235 Filipino, 293 Hawaiian, and 423 white;
mean age ± SD, 59 ± 13 years) with a diagnosis of early breast cancer (stages I, II, and IIIA) in Hawaii from 1995 to 2001.
We linked data from the Surveillance, Epidemiology, and End Results program’s Hawaii Tumor Registry to administrative health
care claims. We evaluated (1) breast-conserving surgery (BCS); (2) radiotherapy after BCS; and (3) chemotherapy for node-positive
disease. We used logistic regression to examine the association between AAPI ethnicity and treatment, adjusting for age, year,
rural residence, tumor size, grade, nodal status, receptor status, prior cancer, comorbidity index, health plan type, and
income.
Results Overall, 60.3% of women had stage I disease, 36.8% had stage II, and 2.9% had stage IIIA. Only 55.6% received BCS, and 85.1%
of these women also received radiation. Of those with nodal involvement (n = 521), 82.7% received chemotherapy. Japanese and
Filipino women were significantly less likely than white women to undergo BCS (for Japanese: adjusted odds ratio, 0.62; 95%
confidence interval, 0.48–0.80; for Filipinos: adjusted odds ratio, 0.47; 95% confidence interval, 0.33–0.66). Filipinos tended
to be less likely than white women to receive radiation after BCS (adjusted odds ratio, 0.80; 95% confidence interval, 0.42–1.49).
AAPI women were as likely as white women to receive adjuvant chemotherapy for nodal spread.
Conclusions We found disparities in the management of early-stage breast cancer among AAPI women, particularly among Japanese and Filipinos.
Further study is needed to determine the reasons for the observed disparities and to understand their effect on health outcomes. 相似文献
6.
Jackson LC Camacho F Levine EA Anderson RT Stewart JH 《American journal of surgery》2008,195(2):164-169
BACKGROUND: Ductal carcinoma in situ (DCIS) of the breast comprises approximately 25% of new breast cancer cases. The aim of this study was to delineate patterns of care for women with DCIS as related to age, tumor characteristics, and race/ethnicity. Further study goals included the identification of predictors of breast-conserving surgery (BCS), adjuvant radiation, and/or hormonal therapy, as well as breast reconstruction after mastectomy. METHODS: The North Carolina Cancer Registry was queried for primary DCIS treated in 1998 and 1999 (n = 1,893). Logistic regression analysis was performed to define the determinants of patterns of care. RESULTS: Thirty-five percent of the women in this study sample underwent mastectomy. Positive predictors of mastectomy included young age (age <50 y vs 70+; odds ratio [OR], 1.55; 95% confidence interval [CI], 1.13-2.11) and larger tumor size (>2 mm vs 0-1 mm; OR, 2.43; 95% CI, 1.63-3.60). Approximately 48% of women who underwent BCS received adjuvant radiation therapy. Factors associated with receiving radiation therapy after BCS include younger age (age <50 vs 70+; OR, 2.12; 95% CI, 1.49-3.03). Approximately 19% of women who underwent BCS received adjuvant hormonal therapy. Positive predictors of receiving adjuvant hormonal therapy after BCS included age of 50 to 60 years versus 70+ (OR, 2.16; 95% CI, 1.36-3.44) and the receipt of radiation therapy (OR, 3.60; 95% CI, 2.55-5.06). Approximately 28% of women who underwent mastectomy received breast reconstruction surgery. Positive predictors of breast reconstruction after mastectomy included age younger than 50 years versus 70+ years (OR, 47.36; 95% CI, 19.45-115.32). African American race was associated negatively with receipt of breast reconstruction after mastectomy (OR, .46; 95% CI, .26-.84). CONCLUSIONS: Treatment strategies for primary surgical therapy for DCIS vary significantly by age. Inconsistencies exist surrounding the use of adjuvant radiation therapy after BCS in women with DCIS. Variations in approaches to reconstructive surgery after mastectomy may be related to age, ethnicity, and/or economic constraints. 相似文献
7.
Tina W. F. Yen MS MD Xiaolin Fan PhD Rodney Sparapani MS Purushuttom W. Laud PhD Alonzo P. Walker MD Ann B. Nattinger MPH MD 《Annals of surgical oncology》2009,16(4):979-988
Background We studied potential risk factors for lymphedema in a contemporary population of older breast cancer patients.
Methods Telephone surveys were conducted among women (65–89 years) identified from Medicare claims as having initial breast cancer
surgery in 2003. Lymphedema was classified by self-report. Surgery and pathology information was obtained from Medicare claims
and the state cancer registries.
Results Of 1,338 patients treated by 707 surgeons, 24% underwent sentinel lymph node biopsy (SLNB) and 57% axillary lymph node dissection
(ALND). At a median of 48 months postoperatively, 193 (14.4%) had lymphedema. Lymphedema developed in 7% of the 319 patients
who underwent SLNB and in 21% of the 759 patients who underwent ALND. When controlling for patient age, tumor size, type of
breast cancer, type of breast and axillary surgery, receipt of radiation, chemotherapy, and hormonal therapy, and surgeon
case volume, the independent predictors of lymphedema were removal of more than five lymph nodes [odds ratio (OR) 4.68–5.61,
95% confidence interval (CI) 1.36–19.74 for 6–15 nodes; OR 10.50, 95% CI 2.88–38.32 for >15 nodes] and presence of lymph node
metastases (OR 1.98, 95% CI 1.21–3.24).
Conclusions Four years postoperatively, 14% of a contemporary, population-based cohort of elderly breast cancer survivors had self-reported
lymphedema. In this group of predominately community-based surgeons, the number of lymph nodes removed is more predictive
of lymphedema rather than whether SLNB or ALND was performed. As more women with breast cancer undergo only SLNB, it is essential
that they still be counseled on their risk for lymphedema.
Presented at the 61st Annual Society of Surgical Oncology Cancer Symposium, Chicago, IL, March 2008. 相似文献
8.
Disparities in the Local Management of Breast Cancer in the US according to Health Insurance Status
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Thomas M. Churilla MD Brian Egleston PhD Richard Bleicher MD Yanqun Dong MD PhD Joshua Meyer MD Penny Anderson MD 《The breast journal》2017,23(2):169-176
Although standard practice guidelines for breast cancer are clear, the interplay between insurance and practice patterns for the US is poorly defined. This study was performed to test for associations between patient insurance status and presentation of breast cancer as well as local therapy patterns in the US, via a large national dataset. We queried the NCI Surveillance, Epidemiology, and End Results data base for breast cancer cases diagnosed from 2007 to 2011 in women aged 18–64 with nonmetastatic ductal/lobular cancers, treated surgically. We tested for associations between insurance status (insured/Medicaid/uninsured) and choice of surgical procedure (mastectomy/breast conserving surgery [BCS]), omission of radiotherapy (RT) following BCS, and administration of post‐mastectomy radiation (PMRT). There were 129,565 patients with localized breast cancer analyzed. The health insurance classification included insured (84.5%), Medicaid (11.5%), uninsured (2.1%) and unknown (1.9%). Medicaid or uninsured status was associated with large, node positive tumors, black race, and low income. The BCS rate varied by insurance status: insured (52.2%), uninsured (47.7%), and Medicaid (45.2%), p < 0.001. In multivariable analysis, Medicaid insurance remained significantly associated with receipt of mastectomy (OR [95% CI] = 1.07 [1.03–1.11]), while RT was more frequently omitted after BCS in both Medicaid (OR [95% CI] = 1.14 [1.07–1.21]) and uninsured (OR [95% CI] = 1.29 [1.14–1.47]) patients. Insurance status was associated with significant variations in breast cancer care in the US. Although patient choice cannot be determined from this dataset, departure from standard of care is associated with specific types of insurance coverage. Further investigation into the reasons for these departures is strongly suggested. 相似文献
9.
Objective Breast carcinoma is the most frequently diagnosed malignancy in women of North America. The combination of breast conservation
surgery and radiotherapy has become a standard of treatment for the majority of breast cancers. It is critical to obtain clear
margins to minimize local recurrence. However, avoiding multiple re-excisions for margin clearance helps optimize cosmetic
results in patients undergoing breast conservation surgery. Intra-operative touch preparation cytology (IOTPC) may decrease
the need for multiple re-excisions and thereby improve cosmesis. The literature suggests that IOTPC can be useful in evaluation
of margins. Klimberg et al. evaluated the touch preparation technique prospectively in 428 patients undergoing breast biopsy
for undiagnosed breast masses. Margin evaluation was correct in 100% of the lesions and was used to re-excise the margins
when touch prep results were positive. They reported a diagnostic accuracy, sensitivity, specificity, positive predictive
value, and negative predictive value of 100% for the touch prep technique.
To the best of our knowledge, there has been no published data on the role of IOTPC for evaluation of margins in re-excision
cases. This report describes our experience with IOTPC for margin assessment for re-excision partial mastectomy at Beth Israel
Medical Center (BIMC). The purpose of this study is to determine whether IOTPC is reliable for evaluating margins in patients
undergoing re-excision for involved or close margins.
Methods A prospective study of 30 patients, who have undergone re-excision partial mastectomy for involved or close margins after
breast conservation surgery with the use of IOTPC for margin assessment at BIMC was performed. The re-excision lumpectomy
specimens were oriented by the surgeon intra-operatively and were submitted fresh to pathology for cytologic assessment. The
touch prep method consisted of touching the corresponding margin onto the glass slide. The principle of this technique is
that if cancer cells are present they will stick to the slide, while fat cells will not. A slide was prepared for each re-excision
specimen. Air-dried samples were stained immediately using the Diff-Quik method and examined under the microscope by a cytopathologist.
Results Thirty patients underwent re-excision lumpectomy for involved or close margins with touch preparation cytology for assessment
of 68 margins. Twenty-six patients had invasive ductal carcinoma and/or ductal carcinoma in situ, three patients had invasive
lobular carcinoma and the remaining one patient had a combination of invasive lobular and ductal carcinoma. There was a correlation
between touch prep cytology and final pathology in 56/68 margins, which accounts for 82.4% of the cases.
Conclusion Intra-operative touch preparation cytology for assessment of margins in patients undergoing re-excision lumpectomy for involved
or close margins has a sensitivity of 75%, specificity of 82.8%, positive predictive value of 21.4%, and negative predictive
value of 98.2%. This high negative predictive value and a single false negative margin are quite significant. Therefore, based
on our experience, IOTPC can be a useful tool for intra-operative assessment of margins for patients undergoing re-excision
partial mastectomy.
Poster presentation at the 28th Annual san Antonio Breast Cancer Symposium, December 8–11, 2005, San Antonio, Texas. 相似文献
10.
Lobna Ouldamer Sofiane Bendifallah Joseph Pilloy Flavie Arbion Gilles Body Caroline Brisson Vincent Lavou Jean Lvêque Emile Daraï 《The breast journal》2019,25(4):696-701
We developed a risk scoring system (RSS) for predicting breast conservative surgery (BCS) in women receiving neoadjuvant chemotherapy(NAC) for breast cancer. BCS rate in the training set was 32.6%, associated with five variables: age < 50years, primary radiological tumor diameter < 60mm, absence of multifocality, absence of breast inflammation and hormone receptor status. These variables were assigned scores ranging from 0 to 9. The discrimination of the RSS was 0.78(95%CI 0.69‐0.86) in the training set. The area under the curve of the receiver operating characteristics for predicting BCS after internal and external validation was 0.77(95%CI 0.68‐0.85) and 0.75(95%CI 0.66‐0.84), respectively. 相似文献
11.
Amer K. Karam MD Meier Hsu MS Sujata Patil PhD Michelle Stempel MS Tiffany A. Traina MD Alice Y. Ho MD Hiram S. Cody MD Elisa R. Port MD Monica Morrow MD Mary L. Gemignani MD MPH 《Annals of surgical oncology》2009,16(7):1952-1958
Background Completion axillary lymph node dissection (CALND) is routinely performed in breast cancer patients with positive sentinel
lymph nodes (SLN). We sought to determine the sociodemographic, pathologic, and therapeutic variables that were associated
with CALND.
Methods From 7/1997 to 7/2003, 1,470 patients with invasive breast cancer were SLN positive by intraoperative frozen section or final
pathologic exam by hematoxylin–eosin and/or immunohistochemistry (IHC). A comorbidity score was assigned using Adult Comorbidity
Evaluation-27 system. Fisher’s exact, Wilcoxon tests, and multivariate logistic regression analysis were used.
Results CALND was performed less often in patients with age ≥ 70 years compared with age < 70 years, moderate or severe comorbidities
compared with no or mild, IHC-only positive SLN and breast conservation therapy (BCT compared with mastectomy. Patients who
did not undergo CALND were less likely than CALND patients to have grade III disease, lymphovascular invasion multifocal disease,
tumor size > 2 cm or to receive adjuvant chemotherapy. However, they were more likely to undergo axillary radiotherapy (RT).
On multivariate analysis, age ≥ 70 years [odds ratio (OR) 0.4, 95% confidence interval (CI) 0.26–0.63], IHC-only positive
SLN (OR 0.13, 95%CI 0.09–0.19), presence of moderate to severe comorbidities (OR 0.64, 95%CI 0.41–0.99), tumor size ≤ 2 cm
(OR 0.44, 95%CI 0.29–0.66), axillary RT (OR 0.39, 95%CI 0.20–0.78), and BCT (OR 0.54, 95%CI 0.37–0.79) were all independently
associated with lower odds of CALND.
Conclusions The decision to perform CALND following positive SLN biopsy was multifactorial. Patient factors were a primary determinant
for the use of CALND in our study. The decreased use of CALND in the BCT patients probably reflects reliance on the radiotherapy
tangents to maintain local control in the axilla. 相似文献
12.
Systematic cavity shaves reduces close margins and re-excision rates in breast conserving surgery 总被引:1,自引:0,他引:1
The role of cavity shaves in reducing re-excision rates in breast conserving surgery (BCS) remains unclear. We compared rates of close margins and re-excision following cavity shaves based on either intraoperative radiology or systematic cavity shaves. Data was recorded prospectively from 1999 to 2003 for 217 patients undergoing BCS. For the first 106 cases, cavity shaves were performed when intraoperative radiological margins appeared close (<10 mm). The remaining 111 cases had systematic superior and inferior cavity shaves (SSICS). Close margins and re-excision rates were compared between groups. The median weight of excised tissue was less in group two: 82.8 g versus 100.5 g, P=0.001. SSICS reduced close margins by 83% (18/106 versus 8/111), OR 0.17, 95% CI 0.08-0.48, P=0.001. Multivariate analysis showed SSICS also reduced re-excision rates (15 versus 8 cases), OR 0.26, 95% CI 0.09-0.74, P=0.012. SSICS reduces close margins and re-excision rates. This approach has additional cosmetic benefits because less tissue is excised. 相似文献
13.
Rebecca J. Tsai MS Leslie K. Dennis PhD Charles F. Lynch MD PhD Linda G. Snetselaar RD PhD LD Gideon K. D. Zamba PhD Carol Scott-Conner MD PhD MBA 《Annals of surgical oncology》2009,16(7):1959-1972
Background As more women survive breast cancer, long-term complications that affect quality of life, such as lymphedema of the arm, gain
greater importance. Numerous studies have attempted to identify treatment and prognostic factors for arm lymphedema, yet the
magnitude of these associations remains inconsistent.
Methods A PubMed search was conducted through January 2008 to locate articles on lymphedema and treatment factors after breast cancer
diagnosis. Random-effect models were used to estimate the pooled risk ratio.
Results The authors identified 98 independent studies that reported at least one risk factor of interest. The risk ratio (RR) of arm
lymphedema was increased after mastectomy when compared with lumpectomy [RR = 1.42; 95% confidence interval (CI) 1.15–1.76],
axillary dissection compared with no axillary dissection (RR = 3.47; 95% CI 2.34–5.15), axillary dissection compared with
sentinel node biopsy (RR = 3.07; 95% CI 2.20–4.29), radiation therapy (RR = 1.92; 95% CI 1.61–2.28), and positive axillary
nodes (RR = 1.54; 95% CI 1.32–1.80). These associations held when studies using self-reported lymphedema were excluded.
Conclusions Mastectomy, extent of axillary dissection, radiation therapy, and presence of positive nodes increased risk of developing
arm lymphedema after breast cancer. These factors likely reflected lymph node removal, which most surgeons consider to be
the largest risk factor for lymphedema. Future studies should consider examining sentinel node biopsy versus no dissection
with a long follow-up time post surgery to see if there is a benefit of decreased lymphedema compared with no dissection. 相似文献
14.
Klimberg VS Kepple J Shafirstein G Adkins L Henry-Tillman R Youssef E Brito J Talley L Korourian S 《Annals of surgical oncology》2006,13(11):1422-1433
Introduction Excision followed by RFA (eRFA) may allow improved cosmesis while ensuring negative margins in patients with breast cancer. This technique utilizes heat to create an additional tumor-free zone around the lumpectomy cavity. We hypothesized that eRFA will decrease the need for re-excision of inadequate margins.Methods Between July 2002 and January 2005, we conducted a multiphase trial of RFA of prophylactic mastectomy specimens and of women desiring lumpectomy. In both models, a lumpectomy was performed, the RFA probe was deployed 1 cm circumferentially into the walls of the lumpectomy cavity and maintained at 100°C for 15 min. Whole mount slides were used to measure the zone of ablation for ex vivo specimens. Hematoxylin and eosin staining of in vivo lumpectomy margins <3 mm was considered inadequate.Results Nineteen prophylactic mastectomy ablations revealed a consistent perimeter of ablation. Forty-one patients (mean age 63 ± 14 years) had an average tumor size of 1.6 ± 1.5 cm underwent in vivo eRFA, and 25% had inadequate margins: one focally positive, one <2 mm, eight <1 mm and one grossly positive. Only the grossly positive margin was re-excised. Overall complication rate of in vivo ablations was 7.5%. Twenty-four of 41 patients did not have post-eRFA XRT. No in-site local recurrences have occurred during a median follow-up of 24 months (12–45 months). Two patients have occurred elsewhere.Conclusions The ex vivo ablation model reliably created a 5–10 mm perimeter of ablation. In vivo, this zone reduced the need for re-excision for inadequate margins by 91% (10/11). Short-term follow-up suggests that eRFA could reduce re-excision surgery and local recurrence. 相似文献
15.
Dillon MF Mc Dermott EW O'Doherty A Quinn CM Hill AD O'Higgins N 《Annals of surgical oncology》2007,14(5):1618-1628
Background Successful breast-conserving therapy in DCIS is restricted by high rates of residual disease resulting in the need for radiotherapy
and/or re-excision. This study identifies patients with DCIS who are most at risk of compromised margins and of residual disease.
Methods All patients undergoing breast-conserving surgery for DCIS over a 6-year period were included. Method of diagnosis, mammographic
size, pathological size, DCIS-margin distance and residual disease on re-excision were analysed.
Results One hundred and thirty-five patients underwent initial breast-conserving surgery for DCIS. The compromised margin rate was
72%, and the rate of residual disease on re-operation was 54%. On univariate analysis, underestimation of pathological size
by mammography by >1 cm occurred in 40% of those with compromised margins undergoing a therapeutic operation compared to only
14% of those with clear margins (P = 0.02). However, on multivariate analysis only pathological size (P < 0.0001, OR = 1.0,95% CI 1.037–1.128) and lack of a preoperative diagnosis by core biopsy (P < 0.0001, OR = 5.3,95% CI 1.859–15.08) were predictive of compromised margins. The presence of residual disease on re-excision
was associated with increasing pathological size (P < 0.0001, OR = 1.085,95% CI 1.038–1.134) and decreasing DCIS-margin distance (P = 0.03, OR = 6.694,95% CI 1.84–37.855). Twenty-nine percent (n = 13/45) of lesions ≤3 cm compared to 84% (n = 27/32) of lesions
>3 cm had residual disease on re-operation (P < 0.0001). Residual disease was present in 62% (n = 34/55), 64% (n = 7/11) and 17% (n = 2/12) of patients with DCIS-margin
distances ≤1, 1–2 and 2–5 mm, respectively.
Conclusion Considerable underestimation of DCIS extent by mammography occurs in a high proportion of patients with compromised margins
in breast conservation. Patients at particularly high risk of residual disease on re-excision are those with lesions >3 cm
and those with DCIS-margin distances of ≤ 2mm. 相似文献
16.
Predictors of Surgical Margin Status in Breast-Conserving Surgery Within a Breast Screening Program 总被引:1,自引:1,他引:0
Kurniawan ED Wong MH Windle I Rose A Mou A Buchanan M Collins JP Miller JA Gruen RL Mann GB 《Annals of surgical oncology》2008,15(9):2542-2549
Background Breast-conserving surgery (BCS) requires clear surgical margins to minimize local recurrence. We sought to identify groups
of patients at higher risk of involved margins who might benefit from preoperative counselling and/or more generous excision
at the first operation.
Methods We reviewed demographic, clinical, radiological and pathological records of all women diagnosed with ductal carcinoma in situ
(DCIS) or invasive cancer (IC) through a population-based breast screening program in Melbourne, Australia between 1994 and
2005.
Results A total of 2,160 women were diagnosed with DCIS or IC. We excluded 199 who had mastectomy (TM) as initial procedure or had
missing data. Three hundred and thirteen had a diagnostic biopsy. Of 1,648 women who had BCS after a preoperative diagnosis
of DCIS or IC, 13.5% had involved margins, 16.6% had close (≤1 mm), and 69.8% clear (>1 mm) margins. Of the patients, 281/1,648
(17.1%) underwent re-excision, of whom 93 (33.1%) had residual disease identified. Mammographic microcalcifications (P < 0.0001), absence of a mammographic mass (P = 0.002), presence of DCIS (P < 0.0001), high tumour grade (P < 0.0001), large size (P < 0.0001), multifocal disease (P < 0.0001) and lobular histology (P = 0.005) were associated with involved margins. Microcalcifications (odds ratio [OR] 1.97), large size (OR 4.22) and multifocal
disease (OR 2.85) were independently associated with involved margins. Residual disease was associated with involved margins
(P < 0.0001), presence of DCIS (P = 0.05) and large tumour size (P = 0.01).
Conclusion After BCS, patients with mammographic microcalcifications, larger tumour size and multifocal tumours are more likely to have
involved margins. Patients with involved margins, large tumour size and/or a DCIS component are more likely to have residual
disease on re-excision. 相似文献
17.
Total Mastectomy or Breast Conservation Therapy? How Radiation Oncologist Accessibility Determines Treatment Choice and Quality: A SEER Data‐base Analysis
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Thomas M. Churilla MD Patrick E. Donnelly PhD Erin R. Leatherman PhD Christian S. Adonizio MD Christopher A. Peters MD 《The breast journal》2015,21(5):473-480
Mastectomy and breast conservation therapy (BCT) are equivalent in survival for treatment of early stage breast cancer. This study evaluated the impact of radiation oncologist accessibility on choice of breast conserving surgery (BCS) versus mastectomy, and the appropriate receipt of radiotherapy after BCS. In the National Cancer Institute Survival, Epidemiology, and End Results data base, the authors selected breast cancer cases from 2004 to 2008 with the following criteria: T2N1M0 or less, lobular or ductal histology, and treatment with simple or partial mastectomy. We combined the Health Resources and Services Administration Area Resource File to define average radiation oncologist density (ROD) by county over the same time period. We evaluated tumor characteristics, demographic information, and ROD with respect to BCS rates and receipt of radiation therapy after BCS in univariable and multivariable analyses. In 118,773 cases analyzed, mastectomy was performed 33.2% of the time relative to BCS. After adjustment for demographic and tumor variables, the odds of having BCS versus mastectomy were directly associated with ROD (multiplicative change in odds for a single unit increase in ROD [95% CI] = 1.02 [1.01–1.03]; p < 0.001). Adjuvant radiation therapy was not administered in 28.2% of BCS cases. When adjusting for demographic and tumor variables, the odds of having BCS without adjuvant radiation were inversely associated with ROD (0.95 [0.94–0.97]; p < 0.001). We observed a direct relationship between ROD and BCS rates independent of demographic and tumor variables, and an inverse trend for omission of radiotherapy after BCS. Access to radiation oncologists may represent an important factor in surgical choice and receiving appropriate BCT in early stage breast cancer. 相似文献
18.
A comparison of ink-directed and traditional whole-cavity re-excision for breast lumpectomy specimens with positive margins 总被引:3,自引:3,他引:0
Gibson GR Lesnikoski BA Yoo J Mott LA Cady B Barth RJ 《Annals of surgical oncology》2001,8(9):693-704
Background: Excising a breast tumor with negative margins minimizes local recurrence. With a positive margin, the standard re-excision consists of excising the whole cavity and all surrounding breast tissue. By marking the sides of the lumpectomy specimen with six different colored inks, the surgeon can limit the re-excision to the involved margin. We compared the local recurrence rate after these two re-excision methods.Methods: Records were reviewed of 527 women (546 breasts) treated with lumpectomy at two institutions. The log-rank test was used to compare the local recurrence–free survival.Results: Of 546 tumors, 245 (45%) had negative margins on the initial lumpectomy and were not re-excised. Fifty-five percent had a positive or close margin; 181 underwent whole-cavity re-excision, and 120 had ink-directed re-excision. The mean follow-up time was 3.4 years. There was no significant difference in local recurrence for the patients whose initial margin was negative (3.7%) compared with the 243 patients with initially positive margins who underwent a re-excision (3.3%). Eleven of 181 (6%) patients undergoing a whole-cavity re-excision developed a local recurrence, compared with none of 120 (0%) patients with an ink-directed re-excision (P = not significant). Tissue mass excised was significantly smaller in the ink-directed group (23 vs. 83 g, P < .05).Conclusions: Ink-directed re-excision of lumpectomy specimens with positive margins minimizes the amount of breast tissue removed without increasing the incidence of local recurrence and is therefore preferable to the standard whole-cavity method. 相似文献
19.
N. Boonyaratavej P. Suriyawongpaisal A. Takkinsatien S. Wanvarie R. Rajatanavin P. Apiyasawat 《Osteoporosis international》2001,12(3):244-248
Hip fractures are among the most important causes of ill health and death among elderly people. Several potentially modifiable
risk factors have been reported. Most claimed physical activity as a promising, inexpensive preventive measure for hip fracture.
However, knowledge about risk factors for hip fracture in Asian populations is very limited. We therefore conducted a case–control
study to assess the relationships between physical activity and risk of hip fractures in Thai women. From 14 hospitals in
Thailand, 229 cases with a radiologically confirmed first hip fracture were enrolled. Two hundred and twenty-four controls
were randomly recruited from the same neighborhood and were matched to the cases by age within a 5 year range. Information
on physical activity as well as other potential confounders was obtained through personal interviews. Multivariate logistic
regression revealed that past physical activity was protective in both very active and active women (OR = 0.67, 95% CI = 0.40–1.12
for moderately active women and OR = 0.20, 95% CI = 0.10–0.38 for very active women; p value for trend <0.01). Recent physical activity reduced the risk to about two-thirds (OR = 0.33, 95% CI = 0.19–0.60 and
OR = 0.35, 95% CI = 0.18–0.69 for moderately and very active women respectively). In addition, breastfeeding was identified
to be a protective factor (OR = 0.87, 95% CI = 0.80–0.94). In contrast, the following risk factors were identified: current
use of antihistamine (OR = 13.96, 95% CI = 1.38–141.13) or traditional medicine (OR = 7.66, 95% CI = 2.71–21.63), underlying
cerebrovascular diseases (OR = 6.53, 95% CI = 2.10–20.34), history of fracture (OR = 4.04, 95% CI = 1.26–12.99), parental
Chinese racial background (OR = 2.52, 95% CI = 1.49–4.23), alcohol consumption (OR = 2.30, 95% CI = 1.04–5.09).
Received: 14 April 2000 / Accepted: 17 October 2000 相似文献
20.
Background Negative surgical margins minimize the risk of local recurrence after breast-conserving surgery. Intraoperative frozen section
analysis (FSA) is one method for margin evaluation. We retrospectively analyzed records of patients who received breast-conserving
therapy with intraoperative FSA of the lumpectomy cavity to assess re-excision rates and local control.
Methods Records were retrospectively reviewed for individuals who underwent breast-conserving surgery for ductal carcinoma in situ
(DCIS) or invasive carcinoma between 1993 and 2003. Inclusion criteria were a minimum of 2 years follow-up and intact tumor
at the time of operation. The major outcome measure was local recurrence. The Kaplan-Meier test was used to evaluate local
recurrence rates between groups.
Results 290 subjects with an average age of 57.2 years (range 27–89) underwent 292 lumpectomies with FSA. 11.3% had DCIS, 73.3% had
infiltrating ductal, 5.8% had infiltrating lobular, and 9.6% exhibited other forms of invasive carcinoma. 70 subjects underwent
additional resection at the time of breast surgery, 16 underwent subsequent re-excision, and 17 underwent subsequent mastectomy.
At a median follow-up of 53.4 months (range 5.8–137.8), there were six local recurrences (2.74%) in patients who had breast-conserving
procedures and two local recurrences in patients who underwent mastectomy. There were no statistically significant associations
among local recurrence rate, tumor size, nodal status, or overall stage. Local recurrences were higher in patients with DCIS
compared with invasive carcinoma, and tumors >2cm.
Conclusions Intraoperative FSA allows resection of suspicious or positive margins at the time of lumpectomy and results in low rates of
local recurrence and re-excision. The low local recurrence rate reported here is comparable to those reported with other margin
assessment techniques. 相似文献