乳腺叶状肿瘤多中心研究挑战切缘指南
乳腺叶状肿瘤比较少见，关于其手术切缘的研究数据更少。现有指南推荐切缘≥1厘米；不过，近年来的研究数据表明，较窄的切缘就足够了，对于良性叶状肿瘤，阴性切缘可能更没必要。
2020年12月10日，美国临床肿瘤学会《临床肿瘤学杂志》在线发表杜克大学、哈佛大学布莱根医院和波士顿妇女医院、达纳法伯癌症研究院、梅奥医学中心、印第安那大学、霍普金斯大学、凯斯西储大学、北卡罗来纳大学、旧金山加利福尼亚大学、威斯康星大学、芝加哥大学、弗吉尼亚大学的研究报告，对最近10年的乳腺叶状肿瘤进行了回顾分析。
该多中心队列研究对2007～2017年美国11个研究中心的550例乳腺叶状肿瘤患者的人口统计学数据、手术数据、组织病理学数据进行回顾分析。采用逻辑回归模型，推算所选影响因素与局部复发的相关性。
结果，其中546例数据完整，大多数进行了切除活检（302例，占55.3%）或肿块切除（210例，占38.5%）。
肿瘤直径中位30毫米，良性肿瘤占68.9%（379例）、交界肿瘤占19.6%（108例）、恶性肿瘤占10.5%（58例）。
切缘阳性占42%（231例）、阴性占57.3%（311例）。
再次手术占38.0%（209例），其中包括51例首次切缘阴性患者（<2毫米占82.4%）和157例首次切缘阳性患者，残留病变仅见6例（2.9%）。
值得注意的是，首次切缘阳性患者未行再次手术占32.0%（74例），其中复发仅占2.7%（2例）。
中位随访36.7个月时，18例（3.3%）复发，其中局部复发15例、远处复发3例。
阴性切缘较宽、最终切缘阴性患者的局部复发（全部叶状肿瘤分级）比例都未显著减少：
≥2毫米与<2毫米相比（比值比：0.39，95%置信区间：0.07～2.10，P=0.27）
切缘阳性与阴性相比（比值比：0.96，95%置信区间：0.26～3.52，P=0.96）
因此，该研究结果表明，在目前临床实践中，许多乳腺叶状肿瘤患者的治疗并未按照现有指南。对于上述患者队列，切缘较宽并未显著减少局部复发风险，故对于良性叶状肿瘤，无论切缘宽度如何，不推荐再次切除阴性切缘，因为增加切缘不太可能减少局部复发。切缘指南应进一步个体化，不应一刀切。
相关链接
J Clin Oncol. 2020 Dec 10. Online ahead of print.
Contemporary Multi-Institutional Cohort of 550 Cases of Phyllodes Tumors (2007-2017) Demonstrates a Need for More Individualized Margin Guidelines.
Rosenberger LH, Thomas SM, Nimbkar SN, Hieken TJ, Ludwig KK, Jacobs LK, Miller ME, Gallagher KK, Wong J, Neuman HB, Tseng J, Hassinger TE, King TA, Jakub JW.
Duke University, Durham, NC; Brigham & Women's Hospital, Dana-Farber Cancer Institute, Boston, MA; Mayo Clinic, Rochester, MN; Indiana University School of Medicine, Indianapolis, IN; Johns Hopkins University School of Medicine, Baltimore, MD; University Hospitals, Case Western Reserve University School of Medicine, Cleveland, OH; University of North Carolina, Chapel Hill, NC; University of California, San Francisco, San Francisco, CA; University of Wisconsin, Madison, WI; University of Chicago Medicine, Chicago, IL; University of Virginia Health System, Charlottesville, VA.
PURPOSE: Phyllodes tumors (PTs) are rare breast neoplasms, which have little granular data on margins. Current guidelines recommend ≥ 1 cm margins; however, recent data suggest narrower margins are sufficient, and for benign PT, a negative margin may not be necessary.
METHODS: We performed an 11-institution contemporary (2007-2017) review of PT practices. Demographics, surgical, and histopathologic data were captured. Logistic regression was used to estimate the association of select covariates with local recurrence (LR).
RESULTS: Of 550 PT patients, the majority underwent excisional biopsy (55.3%, n = 302/546) or lumpectomy (wide excision) (38.5%, n = 210/546). Median tumor size was 30 mm, 68.9% (n = 379) were benign, 19.6% (n = 108) borderline, and 10.5% (n = 58) malignant. Surgical margins were positive in 42% (n = 231) and negative in 57.3% (n = 311). A second operation was performed in 38.0% (n = 209) of the total cohort, including 51 patients with an initial negative margin (82.4% with < 2 mm), and 157 with an initial positive margin, with residual disease only found in six (2.9%). Notably, 32.0% (n = 74) of those with an initial positive margin did not undergo a second operation, among whom only 2.7% (n = 2) recurred. Recurrence occurred in 3.3% (n = 18) of the total cohort (n = 15 LR, n = 3 distant), at median follow-up of 36.7 months. LR (all PT grades) was not reduced with wider negative margin width (≥ 2 mm v < 2 mm: odds ratio [OR] = 0.39; 95% CI, 0.07 to 2.10; P = .27) or final margin status (positive v negative: OR = 0.96; 95% CI, 0.26 to 3.52; P = .96).
CONCLUSION: In current practice, many patients are managed outside of current guidelines. For the entire cohort, a wider margin width was not associated with a reduced risk of LR. We do not recommend re-excision of a negative margin for benign PT, regardless of margin width, as a progressively wider surgical margin is unlikely to reduce LR.
PMID: 33301374
DOI: 10.1200/JCO.20.02647