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乳腺粗針穿刺活檢時，放射狀瘢痕樣病變的診斷率高達45%，由于其可能與并發(fā)惡性腫瘤相關(guān)，故通常建議進行手術(shù)切除。不過，近來發(fā)現(xiàn)放射狀瘢痕手術(shù)切除標本病理檢查惡性率極低，引起對常規(guī)手術(shù)必要性的重新審視。 2018年11月20日，施普林格·自然旗下《乳腺癌研究與治療》在線發(fā)表澳大利亞皇家阿德萊德醫(yī)院、南澳大利亞乳腺癌篩查中心、阿德萊德大學、南澳大利亞大學的研究報告，分析了放射狀瘢痕切除病理檢查惡性率較低的亞組特征，以使影像學監(jiān)測成為手術(shù)的合理替代方案。 該研究對PubMed、Cochrane和Embase數(shù)據(jù)庫進行系統(tǒng)檢索，重點關(guān)注有全文、1998年后發(fā)表、英語、至少5例放射狀瘢痕、提供穿刺活檢標準和手術(shù)切除標本病理檢查惡性率等信息的文獻。將文獻按組織學異型和粗針穿刺活檢標準分組，進行薈萃分析。計算各個亞組的獨立惡性率和匯總惡性率。 結(jié)果，49篇文獻共計3163例放射狀瘢痕手術(shù)結(jié)局符合條件。手術(shù)切除標本病理檢查升級為惡性腫瘤217例，其中浸潤癌71例（32.7%）、導管原位癌144例（66.4%）。根據(jù)隨機效應分析，匯總惡性率為7%（95%置信區(qū)間：5～9%）。 根據(jù)預設(shè)亞組分析，對于14G粗針穿刺活檢評定的放射狀瘢痕，手術(shù)切除標本病理檢查惡性率：
對于8～16G混合粗針穿刺活檢評定的放射狀瘢痕，手術(shù)切除標本病理檢查惡性率：
對于8～11G真空輔助混合粗針穿刺活檢評定的放射狀瘢痕，手術(shù)切除標本病理檢查惡性率：
對于真空輔助活檢切除評定的放射狀瘢痕，手術(shù)切除標本病理檢查惡性率：
所有亞組之間的差異均有統(tǒng)計學意義。 因此，該研究結(jié)果表明，按組織學異型和活檢標準進行分組后，放射狀瘢痕的手術(shù)切除標本病理檢查惡性率基本吻合且可預測。真空輔助活檢評定的非異型放射狀瘢痕，手術(shù)切除標本病理檢查升級為導管原位癌占1%（95%置信區(qū)間：0～4%）。其他組的惡性率為2～28%。通過真空輔助活檢切除可以減少該風險。該薈萃分析結(jié)果為穿刺活檢診斷放射狀瘢痕后的手術(shù)提供了決策輔助工具和循證選擇標準。 相關(guān)閱讀 Breast Cancer Res Treat. 2018 Nov 20. Meta-analysis of upgrade rates in 3163 radial scars excised after needle core biopsy diagnosis. Farshid G, Buckley E. Royal Adelaide Hospital, Adelaide, SA, Australia; BreastScreen South Australia, Adelaide, SA, Australia; Adelaide University, Adelaide, SA, Australia; University of South Australia, Adelaide, SA, Australia. BACKGROUND: Since concurrent malignancy may be associated with radial scars (RS) in up to 45% of RS diagnosed on core biopsy, surgical excision is usually advised. Recent very low upgrade rates have caused a re-evaluation of the need for routine surgery. We aimed to find subsets of RS at such low risk of upgrade, as to render imaging surveillance a plausible alternative to surgery. DESIGN: We performed a systematic review of the Pubmed, Cochrane and Embase databases, focusing on the following eligibility criteria: full papers, published after 1998, in English, included at least 5 RS, provided information on needle biopsy gauge and upgrade rates based on the excised lesion. For the meta-analysis, studies were grouped by the presence of histologic atypia and the core needle gauge. Study-specific and pooled upgrade rates were calculated for each subgroup. RESULTS: 49 studies that included 3163 RS with surgical outcomes are included. There were 217 upgrades to malignancies, 71 (32.7%) invasive and 144 (66.4%) DCIS. The random-effects pooled estimate was 7% (95% CI 5, 9%). Among the pre-planned subgroups, in RS assessed by 14G NCB the upgrade rates were: without atypia - 5% (95% CI 3, 8%), mixed or presence of atypia not specified - 15% (95% CI 10, 20%), with atypia - 29% (95% CI 20, 38%). For RS assessed by a mix of 8-16G cores the respective upgrade rates were 2% (95% CI 1, 4%), 12% (95% CI 6, 18%) and 11% (95% CI 3, 23%) and for RS assessed by 8-11 vacuum assisted biopsies 1% (95% CI 0, 4%), 5% (95% CI 0, 11%) and 18% for the one study of RS with atypia assessed by VAB. Surgery after VAB excision showed no upgrades. The difference across all subgroups was statistically significant. CONCLUSION: When stratified by atypia and biopsy gauge, upgrade rates in RS are consistent and predictable. RS assessed by VABs and lacking atypia have a 1% (95% CI 0, 4%) upgrade rate to DCIS. Other groups have upgrade rates of 2-28%. This risk may be reduced by VAB excision. The results of this meta-analysis provide a decision aid and evidence-based selection criteria for surgery after a needle biopsy diagnosis of RS. KEYWORDS: Breast cancer; Core biopsy; Mammography; Radial scar; Screening PMID: 30460464 DOI: 10.1007/s10549-018-5040-3
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