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磁共振成像和十二基因表达谱评分 可以指导乳腺导管原位癌治疗决策 先进的诊断技术，例如磁共振成像和基因表达谱，可能有助于指导乳腺导管原位癌患者的精准治疗。 2019年1月17日，《美国医学会杂志》肿瘤学分册在线发表哈佛大学麻省总医院、罗德岛布朗大学、芝加哥西北大学、密歇根大学、宾夕法尼亚爱因斯坦医疗网络、印第安纳大学、国家癌症研究所、新奥尔良奥克斯纳医疗中心、西雅图华盛顿大学、新泽西亨特顿医疗中心、宾夕法尼亚朗肯瑙医疗中心、密苏里斯普林菲尔德慈善医院、维克弗里斯特大学、纽约爱因斯坦医学院、纽约纪念医院斯隆凯特林癌症中心的研究报告，分析了磁共振成像后改变为乳房切除术的患者比例及其改变原因，以及患者对乳腺导管原位癌12基因评分指导放疗的依从性。 该东部肿瘤学协作组（ECOG）和美国放射学会成像网络（ACRIN）前瞻队列非随机对照研究（E4112，NCT02352883）于2015年3月25日～2016年4月27日从75个机构入组粗针活检确诊乳腺导管原位癌符合广泛局部切除指征的女性368例，手术前接受乳腺磁共振成像，随后选择手术方案时考虑磁共振成像结果。乳腺导管原位癌12基因评分用于指导最终进行广泛局部切除手术并且无肿瘤切缘≥2厘米患者的放疗推荐意见。主要研究终点为推算改变为乳房切除术的比例及其改变原因。 结果，339例可评估女性（平均年龄59.1±10.1岁，其中欧洲后裔262例，占77.3%）磁共振成像前符合广泛局部切除指征，其中65例（19.2%，95%置信区间：15.3%～23.7%）改变为乳房切除术：
285例磁共振成像后广泛局部切除作为首次手术方案，其中274例（96.1%）实现成功保乳。 171例女性符合乳腺导管原位癌12基因评分指导放疗指征（切缘阴性、无浸润病变、有评分）
因此，该研究结果表明，根据常规成像检查，对于符合广泛局部切除指征的乳腺导管原位癌女性，多种因素与改变为乳房切除术相关。乳腺磁共振成像和12基因检测可以分别对初次手术方案和术后是否放疗进行个体化决策，有助于医患更精准地做出治疗决定。该研究可为随机临床研究方案设计提供所需有用初步信息，以确定磁共振成像和乳腺导管原位癌12基因评分对手术、放疗、医疗资源利用、临床结局的影响，实现更加精准治疗的最终目标。 相关阅读 JAMA Oncol. 2019 Jan 17. [Epub ahead of print] Association of Magnetic Resonance Imaging and a 12-Gene Expression Assay With Breast Ductal Carcinoma In Situ Treatment. Constance D. Lehman; Constantine Gatsonis; Justin Romanoff; Seema A. Khan; Ruth Carlos; Lawrence J. Solin; Sunil Badve; Worta McCaskill-Stevens; Ralph L. Corsetti; Habib Rahbar; Derrick W. Spell; Kenneth B. Blankstein; Linda K. Han; Jennifer L. Sabol; John R. Bumberry; Ilana Gareen; Bradley S. Snyder; Lynne I. Wagner; Kathy D. Miller; Joseph A. Sparano; Christopher Comstock. Massachusetts General Hospital, Harvard Medical School, Boston; Brown University School of Public Health, Providence, Rhode Island; Northwestern University, Chicago, Illinois; University of Michigan, Ann Arbor; Albert Einstein Healthcare Network, Philadelphia, Pennsylvania; Indiana University, Indianapolis; National Cancer Institute, Bethesda, Maryland; Ochsner Medical Center, New Orleans, Louisiana; University of Washington, Seattle; Gulf South National Cancer Institute Community Oncology Research Program, New Orleans, Louisiana; Hunterdon Medical Center, Flemington, New Jersey; Lankenau Medical Center, Wynnewood, Pennsylvania; Mercy Hospital, Springfield, Missouri; Wake Forest University Health Sciences, Winston Salem, North Carolina; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York; Memorial Sloan Kettering Cancer Center, New York, New York. This nonrandomized clinical trial of women with ductal carcinoma in situ examines reasons for conversion to mastectomy after magnetic resonance imaging and adherence to radiotherapy use guided by the 12-gene ductal carcinoma in situ score.
IMPORTANCE: Advanced diagnostics, such as magnetic resonance imaging (MRI) and gene expression profiles, are potentially useful to guide targeted treatment in patients with ductal carcinoma in situ (DCIS). OBJECTIVES: To examine the proportion of patients who converted to mastectomy after MRI and the reasons for those conversions and to measure patient adherence to radiotherapy guided by the 12-gene DCIS score. DESIGN, SETTING, AND PARTICIPANTS: Analysis of a prospective, cohort, nonrandomized clinical trial that enrolled women with DCIS on core biopsy who were candidates for wide local excision (WLE) from 75 institutions from March 25, 2015, to April 27, 2016, through the Eastern Cooperative Oncology Group - American College of Radiology Imaging Network trial E4112. INTERVENTIONS: Participants underwent breast MRI before surgery, and subsequent management incorporated MRI findings for choice of surgery. The DCIS score was used to guide radiotherapy recommendations among women with DCIS who had WLE as the final procedure and had tumor-free excision margins of 2 mm or greater. MAIN OUTCOMES AND MEASURES: The primary end point was to estimate the conversion rate to mastectomy and the reason for conversion. RESULTS: Of 339 evaluable women (mean [SD] age, 59.1 [10.1] years; 262 [77.3%] of European descent) eligible for WLE before MRI, 65 (19.2%; 95% CI, 15.3%-23.7%) converted to mastectomy. Of these 65 patients, conversion was based on MRI findings in 25 (38.5%), patient preference in 25 (38.5%), positive margins after attempted WLE in 10 (15.4%), positive genetic test results in 3 (4.6%), and contraindication to radiotherapy in 2 (3.1%). Among the 285 who had WLE performed after MRI as the first surgical procedure, 274 (96.1%) achieved successful breast conservation. Of 171 women eligible for radiotherapy guided by DCIS score (clear margins, absence of invasive disease, and score obtained), the score was low (<39) in 82 (48.0%; 95% CI, 40.6%-55.4%) and intermediate-high (≥39) in 89 (52.0%; 95% CI, 44.6%-59.4%). Of these 171 patients, 159 (93.0%) were adherent with recommendations. CONCLUSIONS AND RELEVANCE: Among women with DCIS who were WLE candidates based on conventional imaging, multiple factors were associated with conversion to mastectomy. This study may provide useful preliminary information required for designing a planned randomized clinical trial to determine the effect of MRI and DCIS score on surgical management, radiotherapy, overall resource use, and clinical outcomes, with the ultimate goal of achieving greater therapeutic precision. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02352883 DOI: 10.1001/jamaoncol.2018.6269 |
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