Meme Kanseri Nedeni ile Meme Koruyucu Cerrahi Uygulanan Hastalarda Re-eksizyon Uygulanmasını Etkileyen Faktörler

Yıl 2022, Cilt: 8 Sayı: 3, 298 - 305, 01.09.2022

Demet Sarıdemir Ünal Mustafa Saraçoğlu Volkan Doğru Muhittin Yaprak Ayhan Mesci Cumhur Arıcı Ahmet Nezihi Oygür

https://doi.org/10.53394/akd.1059393

Öz

Öz
Amaç: Meme koruyucu cerrahi geçiren hastaların önemli bir bölümünde rezidü kanser için re-eksizyon gereksinimi ortaya çıkmaktadır. Bu çalışmanın amacı, Meme koruyucu cerrahi uygulanan hastalarda rezidü tümör ile ilişkili faktörlerin belirlenmesi ve hastaların takip sonuçlarını değerlendirmektir.
Gereç ve Yöntemler: Altı yıllık sürede, meme koruyucu cerrahi uygulanan hastalar çalışmaya alındı. Hastalar iki gruba ayrılarak incelendi: re-eksizyon yapılmayanlar (Grup A), re-eksizyon yapılanlar (Grup B). Takiplerinde mastektomi yapılan hastalar çalışmadan çıkarıldı.
Bulgular: Çalışmaya, 153’ü Grup A ve 37’si Grup B’de toplam 190 hasta dahil edildi. Toplamda 192 tümör saptandı; 154’ü Grup A, 38’i Grup B’de. Medyan takip süresi 9,2 yıl (Çeyrekler arası aralık [ÇAA]=5,9-11,1), medyan hastalıksız sağ kalım süresi 8,8 yıldı (ÇAA=5,0-11,0). Takiplerinde iki grup arasında hastalıksız sağ kalım ve lokal nüks açısından anlamlı fark olmadığı görüldü (sırasıyla; p=0.246, p=0.601). Genç hasta, büyük tümör çapı, lenfovasküler invazyon, aksiller lenf nodu tutulumu, yaygın intraduktal kompanent varlığı ve multifokalite, re-eksizyon grubunda fazlaydı. Çoklu değişken analiz, yaş >50 (Odds ratio [OR] 0,17 ve %95Cl 0,04-0,73) ve lenfovasküler invazyon yokluğunun (OR 0,05 ve %95Cl 0,01-0,44); re-eksizyon riskini azalttığını, tümör çapının 2 cm’den büyük olmasının (OR 4,52 ve %95Cl 1,28-15,98); re-eksizyon riskini arttırdığını gösterdi.
Sonuç: Re-eksizyon yapılan ve yapılmayan hastalar arasında hastalıksız sağ kalım ve lokal nüks açısından fark yoktur. Riskli hastalar, tanı aşamasında re-eksizyon ihtimali konusunda bilgilendirilmeli, bu hastalarda daha geniş cerrahi eksizyon veya onkoplastik yöntemler tercih edilmelidir.

Anahtar Kelimeler: Meme koruyucu cerrahi, Re-eksizyon, Erken evre meme kanseri

Anahtar Kelimeler

Meme koruyucu cerrahi, Re-eksizyon, Erken evre meme kanseri

Factors Influencing The Practice of Re-excision in Patiens Who Underwent Breast Conserving Surgery for Breast Cancer

Öz

Abstract
Objective: A significant proportion of patients undergoing breast-conserving surgery require re-excision for residual cancer. This study aims to determine the factors associated with residual tumor in patients undergoing breast conserving surgery, and to evaluate the follow-up results of the patients.
Material and Methods: Patients underwent breast-conserving surgery in a 6-year period were included in this study. Patients were divided in 2 groups; no re-excision (Group A), and required re-excision (Group B). Patients who underwent mastectomy in the follow-up were excluded.
Results: In this study, 190 patients were assessed; those 153 in Group A, and 37 in Group B. A total 192 masses were found; 154 in Group A, and 38 in Group B. The median follow-up time, and disease free survival were 9.2 (Inter Quantile Range [IQR]=5.9-11.1) years, and 8.8 (IQR=5.0-11.0) years respectively. There was no difference in disease free survival, and local recurrence between groups (p=0.246, and p=0.601; respectively). Axillary lymph node involvement, lymphovascular invasion, extensive intraductal companent, multifocality, large tumor diameter and younger age patients were higher in re-excision group. Multivariate anlysis identified, absence of lymphovascular invasion (Odds Ratio [OR]=0.05; %95Cl 0.01-0,44), and age >50 years (OR=0.17; %95Cl 0.04-0.73) were associated with lower re-excision requirement; however, tumor diameter >2 cm (OR=4.52;%95Cl 1.28-15.98) was associated with re-excision.
Conclusion: There was no difference in disease free survival, and local recurrence between 2 groups. Patients should be informed for the risk of re-excision after initial breast conservig surgery and wider surgical excision or oncoplastic surgery should be performed in risky patients.

Key Words: Breast conserving surgery, Re-excision, Early stage breast cancer.

Anahtar Kelimeler

Breast conserving surgery, Re-excision, Early stage breast cancer.

Kaynakça

• 1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin [Internet]. 2018 Nov [cited 2021 Feb 24];68(6):394–424. Available from: https://pubmed.ncbi.nlm.nih.gov/30207593/
• 2. Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch M, Fisher ER, et al. Twenty-Year Follow-up of a Randomized Trial Comparing Total Mastectomy, Lumpectomy, and Lumpectomy plus Irradiation for the Treatment of Invasive Breast Cancer. N Engl J Med [Internet]. 2002 Oct 17 [cited 2021 Feb 24];347(16):1233–41. Available from: https://pubmed.ncbi.nlm.nih.gov/12393820/
• 3. Veronesi U, Banfi A, Salvadori B, Luini A, Saccozzi R, Zucali R, et al. Breast conservation is the treatment of choice in small breast cancer: Long-term results of a randomized trial. Eur J Cancer Clin Oncol [Internet]. 1990 [cited 2021 Feb 24];26(6):668–70. Available from: https://pubmed.ncbi.nlm.nih.gov/2144152/
• 4. Waljee JF, Hu ES, Newman LA, Alderman AK. Predictors of re-excision among women undergoing breast-conserving surgery for cancer. Ann Surg Oncol [Internet]. 2008 May 8 [cited 2021 Feb 24];15(5):1297–303. Available from: https://link.springer.com/article/10.1245/s10434-007-9777-x
• 5. Ozmen V, Ozmen T, Dogru V. Breast Cancer in Turkey; An Analysis of 20.000 Patients with Breast Cancer. Eur J Breast Heal [Internet]. 2019 Jul 2 [cited 2021 Feb 24];15(3):141–6. Available from: https://pubmed.ncbi.nlm.nih.gov/31312788/
• 6. Obedian E, Haffty BG. Negative margin status improves local control in conservatively managed breast cancer patients. Cancer J Sci Am. 2000;6(1):28–33.
• 7. Singer L, Brown E, Lanni T. Margins in breast conserving surgery: The financial cost & potential savings associated with the new margin guidelines. Breast. 2016 Aug 1;28:1–4.
• 8. Abraham J, Aft R, Agnese D, Allison KH, Anderson BO, Blair SL, et al. NCCN Guidelines Version 1.2021 Breast Cancer. 2021.
• 9. Tran C-L, Langer S, Broderick-Villa G, DiFronzo LA. Does reoperation predispose to postoperative wound infection in women undergoing operation for breast cancer? Am Surg. 2003 Oct;69(10):852–6.
• 10. Smitt MC, Horst K. Association of clinical and pathologic variables with lumpectomy surgical margin status after preoperative diagnosis or excisional biopsy of invasive breast cancer. Ann Surg Oncol. 2007 Mar;14(3):1040–4.
• 11. O’Sullivan MJ, Li T, Freedman G, Morrow M. The effect of multiple reexcisions on the risk of local recurrence after breast conserving surgery. Ann Surg Oncol. 2007 Nov;14(11):3133–40.
• 12. Aziz D, Rawlinson E, Narod SA, Sun P, Lickley HLA, McCready DR, et al. The role of reexcision for positive margins in optimizing local disease control after breast-conserving surgery for cancer. Breast J. 2006;12(4):331–7.
• 13. Bani MR, Lux MP, Heusinger K, Wenkel E, Magener A, Schulz-Wendtland R, et al. Factors correlating with reexcision after breast-conserving therapy. Eur J Surg Oncol J Eur Soc Surg Oncol Br Assoc Surg Oncol. 2009 Jan;35(1):32–7.
• 14. Keskek M, Kothari M, Ardehali B, Betambeau N, Nasiri N, Gui GPH. Factors predisposing to cavity margin positivity following conservation surgery for breast cancer. Eur J Surg Oncol J Eur Soc Surg Oncol Br Assoc Surg Oncol. 2004 Dec;30(10):1058–64.
• 15. Luu HH, Otis CN, Reed WPJ, Garb JL, Frank JL. The unsatisfactory margin in breast cancer surgery. Am J Surg. 1999 Nov;178(5):362–6.
• 16. Mullenix PS, Cuadrado DG, Steele SR, Martin MJ, See CS, Beitler AL, et al. Secondary operations are frequently required to complete the surgical phase of therapy in the era of breast conservation and sentinel lymph node biopsy. In: American Journal of Surgery [Internet]. Am J Surg; 2004 [cited 2021 Feb 24]. p. 643–6. Available from: https://pubmed.ncbi.nlm.nih.gov/15135683/
• 17. Beron PJ, Horwitz EM, Martinez AA, Wimbish KJ, Levine AJ, Gustafson G, et al. Pathologic and mammographic findings predicting the adequacy of tumor excision before breast-conserving therapy. Am J Roentgenol [Internet]. 1996 [cited 2021 Feb 24];167(6):1409–14. Available from: https://pubmed.ncbi.nlm.nih.gov/8956568/
• 18. Kirova YM, Stoppa-Lyonnet D, Savignoni A, Sigal-Zafrani B, Fabre N, Fourquet A. Risk of breast cancer recurrence and contralateral breast cancer in relation to BRCA1 and BRCA2 mutation status following breast-conserving surgery and radiotherapy. Eur J Cancer. 2005;41(15):2304–11.
• 19. Brekelmans CT, Voogd AC, Botke G, van Geel BN, Rodrigus P, Rutgers EJ, et al. Family history of breast cancer and local recurrence after breast-conserving therapy. The Dutch Study Group on Local Recurrence after Breast Conservation (BORST). Eur J Cancer. 1999 Apr;35(4):620–6.
• 20. Chabner E, Nixon A, Gelman R, Hetelekidis S, Recht A, Bornstein B, et al. Family history and treatment outcome in young women after breast-conserving surgery and radiation therapy for early-stage breast cancer. J Clin Oncol Off J Am Soc Clin Oncol. 1998 Jun;16(6):2045–51.
• 21. Smitt MC, Horst K. Association of Clinical and Pathologic Variables with Lumpectomy Surgical Margin Status after Preoperative Diagnosis or Excisional Biopsy of Invasive Breast Cancer.
• 22. Burstein HJ, Polyak K, Wong JS, Lester SC, Kaelin CM. Ductal Carcinoma in Situ of the Breast. N Engl J Med [Internet]. 2004 Apr 8 [cited 2021 Jun 9];350(14):1430–41. Available from: http://www.nejm.org/doi/abs/10.1056/NEJMra031301
• 23. Smitt MC, Nowels K, Carlson RW, Jeffrey SS. Predictors of reexcision findings and recurrence after breast conservation. Int J Radiat Oncol Biol Phys. 2003 Nov;57(4):979–85.
• 24. Lovrics PJ, Cornacchi SD, Farrokhyar F, Garnett A, Chen V, Franic S, et al. The relationship between surgical factors and margin status after breast-conservation surgery for early stage breast cancer. Am J Surg. 2009 Jun;197(6):740–6.
• 25. Kurniawan ED, Wong MH, Windle I, Rose A, Mou A, Buchanan M, et al. Predictors of surgical margin status in breast-conserving surgery within a breast screening program. Ann Surg Oncol. 2008 Sep;15(9):2542–9.
• 26. Cellini C, Huston TL, Martins D, Christos P, Carson J, Kemper S, et al. Multiple re-excisions versus mastectomy in patients with persistent residual disease following breast conservation surgery. Am J Surg. 2005 Jun;189(6):662–6.
• 27. Chagpar AB, Martin RCG 2nd, Hagendoorn LJ, Chao C, McMasters KM. Lumpectomy margins are affected by tumor size and histologic subtype but not by biopsy technique. Am J Surg. 2004 Oct;188(4):399–402.
• 28. Pan Z, Zhu L, Li Q, Lai J, Peng J, Su F, et al. Predicting initial margin status in breast cancer patients during breast-conserving surgery. Onco Targets Ther. 2018;11:2627–35.
• 29. Meier-Meitinger M, Rauh C, Adamietz B, Fasching PA, Schwab SA, Haeberle L, et al. Accuracy of radiological tumour size assessment and the risk for re-excision in a cohort of primary breast cancer patients. Eur J Surg Oncol J Eur Soc Surg Oncol Br Assoc Surg Oncol. 2012 Jan;38(1):44–51.
• 30. Sabel MS, Rogers K, Griffith K, Jagsi R, Kleer CG, Diehl KA, et al. Residual disease after re-excision lumpectomy for close margins. J Surg Oncol. 2009 Feb;99(2):99–103.
• 31. Borger J, Kemperman H, Hart A, Peterse H, van Dongen J, Bartelink H. Risk factors in breast-conservation therapy. J Clin Oncol Off J Am Soc Clin Oncol. 1994 Apr;12(4):653–60.
• 32. Tartter PI, Bleiweiss IJ, Levchenko S. Factors associated with clear biopsy margins and clear reexcision margins in breast cancer specimens from candidates for breast conservation. J Am Coll Surg. 1997 Sep;185(3):268–73.
• 33. Marinovich ML, Noguchi N, Morrow M, Houssami N. Changes in Reoperation After Publication of Consensus Guidelines on Margins for Breast-Conserving Surgery: A Systematic Review and Meta-analysis. JAMA Surg. 2020 Aug;155(10):e203025.
• 34. Landercasper J, Attai D, Atisha D, Beitsch P, Bosserman L, Boughey J, et al. Toolbox to Reduce Lumpectomy Reoperations and Improve Cosmetic Outcome in Breast Cancer Patients: The American Society of Breast Surgeons Consensus Conference. Ann Surg Oncol. 2015;22(10):3174–83.
• 35. Down SK, Jha PK, Burger A, Hussien MI. Oncological advantages of oncoplastic breast-conserving surgery in treatment of early breast cancer. Breast J. 2013;19(1):56–63.
• 36. Santos G, Urban C, Edelweiss MI, Zucca-Matthes G, de Oliveira VM, Arana GH, et al. Long-Term Comparison of Aesthetical Outcomes After Oncoplastic Surgery and Lumpectomy in Breast Cancer Patients. Ann Surg Oncol [Internet]. 2015 Aug 1 [cited 2021 Feb 24];22(8):2500–8. Available from: https://pubmed.ncbi.nlm.nih.gov/25519931/
• 37. Vos EL, Jager A, Verhoef C, Voogd AC, Koppert LB. Overall survival in patients with a re-excision following breast conserving surgery compared to those without in a large population-based cohort. Eur J Cancer [Internet]. 2015;51(3):282–91. Available from: http://dx.doi.org/10.1016/j.ejca.2014.12.003
• 38. Fisher S, Yasui Y, Dabbs K, Winget M. Re-excision and survival following breast conserving surgery in early stage breast cancer patients: A population-based study. BMC Health Serv Res [Internet]. 2018 Feb 8 [cited 2021 Feb 24];18(1):94. Available from: https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-018-2882-7