不同近似分子亚型的乳腺癌保乳术手术切缘的选择

Margin selection for breast-conserving surgery in patients with different approximate molecular subtypes of breast cancer

目的分析乳腺癌保乳术中不同距离切缘状态与雌激素受体(estrogen receptor,ER)、孕激素受体(progestogen receptor,PR)及HER-2表达的相关性,探讨不同近似分子亚型乳腺癌保乳术合适的阴性切缘距离。方法入组80例接受保乳术的乳腺癌患者,术中切除肿瘤及肿瘤周围2cm正常组织,冰冻切片报告切缘阳性者,改行改良根治术。对肿瘤6个方位进行标记,在每个方位上距肿瘤5、10、15、20mm处取组织进行病理学检测。根据肿瘤组织免疫组化ER、PR、HER-2表达情况将乳腺癌划分为4个近似分子亚型,对不同类型患者阴性切缘距离进行统计学分析,筛选不同分析亚型下合适的手术切缘。结果 80例患者距癌旁5、10、15、20mm处切缘阴性率为51.25%、81.25%、97.50%、98.75%,15mm、20mm处切缘阴性率明显高于5mm、10mm处,差异具有统计学意义(P<0.05)。LuminalA型乳腺癌患者10mm处切缘阴性率达97.4%,与5mm处阴性率差异具有统计学意义(P<0.05),与15mm处差异无统计学意义。三阴型患者15mm处切缘阴性率达100%,与10mm处差异具有统计学意义(P<0.05)。LuminalB型及HER-2阳性型各距离切缘阴性率间差异无统计学意义。结论不同近似分子亚型乳腺癌保乳术的阴性手术切缘距离存在差异:LuminalA型患者合适的手术切缘可能为10mm;三阴型乳腺癌患者可能为15mm;而LuminalB型和HER-2阳性型患者可能为20mm,必要时甚至需要进一步扩大。

Objective To analyze the correlation of the statuses of different lumpectomy margins and the expression of estrogen receptor（ER）,progestogen receptor（PR） and HER-2 in breast conserving surgery,so as to explore the suitable width for negative margin in different approximate molecular subtypes of breast cancer.Methods A total of 80 patients who met the standard of breast conserving therapy were included in our study.The width of the surgical margin was 2 cm.Modified radical mastectomy was performed when the intraoperative frozen section examination showed positive margins.Margins of different widths（5 mm,10 mm,15 mm,and 20 mm） at six directions（superior,inferior,left,right,anterior,and posterior） were examined pathologically after operation.The patients were divided into four approximate molecular subtypes according to the immunohistochemical examination of ER,PR and HER-2.The widths of negative margins in the four subtypes were analyzed statistically to select the suitable width of surgical margin for different subtypes.Results The negative rates of 5 mm,10 mm,15 mm,and 20 mm margin widths were 51.25%,81.25%,97.50% and 98.75%,respectively.The negative rates for 15 mm,20 mm margins were significantly higher than those for 5 mm,10 mm margins（P0.05）.The negative rate was 97.4% on the width of 10 mm in Luminal-A,significantly higher than that on the width of 5 mm（P0.05） and not significantly different from that on the width of 15 mm.The negative rate was 100% on the width of 15 mm in patients with triple negative breast cancer,significantly higher than that on the width of 10 mm（P0.05）.There were no significant differences in the negative rates between different widths in both Luminal-B and HER-2 ＋ groups.Conclusion The widths of negative surgical margins are different for different subtypes：10 mm might be suitable for margin width of Luminal-A and 15 mm for that of triple negative breast cancer.As for Luminal-B and HER-2 ＋ types,20 mm or even wider margins might be suitable.