* Fisher B, Anderson S, Bryant J, et al: N Engl J Med 2002; 347:

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2 * Fisher B, Anderson S, Bryant J, et al: N Engl J Med 2002; 347:

3 **Lisa A. Newman: Ann. Surg. Oncol. Vol. 14, No. 8, 2007

4 * Voogd AC, van Oost FJ, Rutgers EJ, Elkhuizen PH, van Geel AN, Scheijmans LJ et al (2005) Long-term prognosis of patients with local recurrence after conservative surgery and radiotherapy for early breast cancer. Eur J Cancer 41:

5 * Kurtz JM, Amalric R, Brandone H, Ayme Y, Spitalier JM (1988) Results of salvage surgery for mammary recurrence following breast-conserving therapy. Ann Surg 207:

6 * Komoike Y, Akiyama F, Iino Y, Tanaka-Akashi S, Ohsumi S, Ikeda T et al (2005) Analysis of ipsilateral breast tumor recurrences after breast-conserving treatment based on the classification of true recurrences and new primary tumors. Breast Cancer 12:

7 * Komoike Y, Akiyama F, Iino Y, Tanaka-Akashi S, Ohsumi S, Ikeda T et al (2005) Analysis of ipsilateral breast tumor recurrences after breast-conserving treatment based on the classification of true recurrences and new primary tumors. Breast Cancer 12:

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9 Iniziale trattamento di QUART Mastectomia totale + staging linfonodale di I e II livello se non eseguito Solo Ripresa locale Iniziale trattamento di Mastectomia + dissezione ascellare I e II livello + RT Resezione Chirurgica se possibile Iniziale trattamento di Mastectomia senza precedente RT Resezione Chirurgica se possibile + RT alla parete toracica e linfonodi infra- e sovra-claveari

10 Solo Regionale o Ripresa loco- Regionale Ripresa ascellare Recidiva sovraclaveare Ai linfonodi della mammaria interna Resezione chirurgica se possibile + RT se possibile a parete toracica, linfonodi sovra e infraclavicolari e ascella RT se possibile a parete toracica e linfonodi sovra e sottoclavicolari RT se possibile a parete toracica, linfonodi sovra- sottoclavicolari e mammaria interna.

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12 La grandezza del tumore (T) pare non avere impatto diretto sul controllo locale di malattia. *Komoike Y, Akiyama F, Iino Y, Ikeda T, Akashi-Tanaka S, Ohsumi S et al (2006) Ipsilateral breast tumor recurrence (IBTR) after breastconserving treatment for early breast cancer: risk factors and impact on distant metastases. Cancer 106:35 41

13 * Taghian A, Mohiuddin M, Jagsi R, Goldberg S, Ceilley E, Powell S (2005) Current perceptions regarding surgical margin status after breast-conserving therapy: results of a survey. Ann Surg 241: , ** Horst KC, Smitt MC, Goffinet DR, Carlson RW (2005) Predictors of local recurrence after breast-conservation therapy. Clin Breast Cancer 5:

14 * Zavagno G, Goldin E, Mencarelli R, Capitanio G, Bianco PD, Marconato R et al (2008) Role of resection margins in patients treated with breast conservation surgery. Cancer 112: ** EBCTCG (2005) Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet 366:

15 * Komoike Y, Akiyama F, Iino Y, Ikeda T, Akashi-Tanaka S, Ohsumi S et al (2006) Ipsilateral breast tumor recurrence (IBTR) after breast-conserving treatment for early breast cancer: risk factors and impact on distant metastases. Cancer 106:35 41, doi: /cncr.21551s

16 * Veronesi U, Salvadori B, Luini A, Greco M, Saccozzi R,del Vecchio M et al (1995) Breast conservation is a safe method in patients with small cancer of the breast. Longterm results of three randomised trials on 1,973 patients. Eur J Cancer 31A:

17 **DiBiase SJ, Komarnicky LT, Schwartz GF, Xie Y, Mansfield CM (1998) The number of positive margins influences the outcome of women treated with breast predibiase SJ, Komarnicky LT, Schwartz GF, Xie Y, Mansfield CM (1998) The number of positive margins influences the outcome of women treated with breast preservation for early stage breast carcinoma. Cancer 82:

18 * Darvishian F, Hajdu SI, DeRisi DC (2003) Significance of linear extent of breast carcinoma at surgical margin. Ann Surg Oncol 10:48 51

19 * Freedman G, Fowble B, Hanlon A, Nicolaou N, Fein D, Hoffman J et al (1999) Patients with early stage invasive cancer with close or positive margins treated with conservative surgery and radiation have an increased risk of breast recurrence that is delayed by adjuvant systemic therapy. Int J Radiat Oncol Biol Phys 44: ** Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch M, Fisher ER et al (2002) 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 347: *** Clarke M, Collins R, Darby S, Davies C, Elphinstone P, Evans E et al (2005) Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet 366:

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25 Nell impiego della chirurgia conservativa della mammella è auspicabile assicurare un margine di resezione negativo. Casi in cui il margine è positivo dovrebbero essere sottoposti a un ulteriore trattamento chirurgico: una riresezione per assicurare dei margini negativi una mastectomia. Se la riresezione è possibile questa va eseguita coinvolgendo il margine risultato positivo e guidati dall orientamento del pezzo della resezione primitiva, ovvero la riresezione deve interessare l intera cavità escissionale. Se i margini positivi sono multipli potrebbe essere richiesta la mastectomia per un controllo locale ottimale.

26 Potrebbe essere ragionevole non reintervenire in casi selezionati di terapia conservativa della mammella che presentino un margine solo focalmente positivo alla microscopia ed in assenza di estesa componente intraduttale. Per questi pazienti potrebbe essere preso in considerazione un più alto boost di radiazioni del letto tumorale.

27 I margini dovrebbero essere valutati, nella terapia conservativa, sul pezzo chirurgico intero. Una ottimale valutazione dei margini richiede: Un corretto orientamento spaziale del pezzo Descrizione macro e microscopica dello stato dei margini Registrazione orientata delle distanze tra limite del tumore e margine di resezione e tipo di tumore (invasivo o DCIS).

28 * Kurtz JM, Jacquemier J, Amalric R, Brandone H, Ayme Y, Hans D et al (1990) Risk factors for breast recurrence in premenopausal and postmenopausal patients with ductal cancers treated by conservation therapy. Cancer 65:

29 * Kurtz JM, Jacquemier J, Amalric R, Brandone H, Ayme Y, Hans D et al (1990) Risk factors for breast recurrence in premenopausal and postmenopausal patients with ductal cancers treated by conservation therapy. Cancer 65:

30 * Mansfield CM, Komarnicky LT, Schwartz GF, Rosenbrg AL, Krishnan L, Jewell WR et al (1995) Ten-year results in 1070 patients with stages I and II breast cancer treated by conservative surgery and radiation therapy. Cancer 75:

31 ** Jakesz R, Hausmaninger H (2002) Randomized adjuvant trial of tamoxifen and goserelin vs. CMF: evidence for the superiority of treatment with endocrine blockade in premenopausal patients with hormone-responsive breast cancer ABCCSG Trial 5. J Clin Oncol :20.

32 * U Veronesi, Cascinelli N, Mariani L, Greco M, Saccozzi R, Luini A et al (2002) Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med 347: * van Dongen JA, Voogd AC, Fentiman IS, Legrand C, Sylvester RJ, Tong D et al (2000) Long-term results of a randomized trial comparing breast-conserving therapy with mastectomy: European Organization for Research and Treatment of Cancer trial. J Natl Cancer Inst 92:

33 * Coulombe G, Tyldesley S, Speers C, Paltiel C, Aquino-Parsons C, Bernstein V et al (2007) Is mastectomy superior to breastconserving treatment for young women? Int J Radiat Oncol Biol Phys 67:

34 * Neuschatz AC, DiPetrillo T, Safaii H, Price LL, Schmidt-Ullrich RK,Wazer DE (2003) Long-term followup of a prospective policy of margin-directed radiation dose escalation in breast-conserving therapy. Cancer 97:30 39

35 * van Dongen JA, Bartelink H, Fentiman IS, Lerut T, Mignolet F, Olthuis G et al (1992) Factors influencing local relapse and survival and results of salvage treatment after breast-conserving therapy in operable breast cancer: EORTC trial 10801, breast conservation compared with mastectomy in TNM stage I and II breast cancer. Eur J Cancer 28A: ** Fowble B, Solin LJ, Schultz DJ, Rubenstein J, Goodman RL (1990) Breast recurrence following conservative surgery and radiation: patterns of failure, prognosis, and pathologic findings from mastectomy specimens with implications for treatment. Int J Radiat Oncol Biol Phys 19: ***Abner AL, Recht A, Eberlein T, Come S, Shulman L, Hayes D et al (1993) Prognosis following salvage mastectomy for recurrence in the breast after conservative surgery and radiation therapy for early-stage breast cancer. J Clin Oncol 11:44 48

36 * Kurtz JM, Amalric R, Brandone H, Ayme Y, Spitalier JM (1988) Results of wide excision for mammary recurrence after breast conserving therapy. Cancer 61:

37 * Kurtz JM, Jacquemier J, Amalric R, Brandone H, Ayme Y, Hans D et al (1991) Is breast conservation after local recurrence feasible? Eur J Cancer 27:

38 * Komoike Y, Motomura K, Inaji H, Kasugai T, Koyama H (2003) Repeat lumpectomy for patients with ipsilateral breast tumor recurrence after breast-conserving surgery. Preliminary results. Oncology 64:1 6 ** Salvadori B, Marubini E, Miceli R, Conti AR, Cusumano F, Andreola S et al (1999) Reoperation for locally recurrent breast cancer in patients previously treated with conservative surgery. Br J Surg 86:84 87

39 ** Salvadori B, Marubini E, Miceli R, Conti AR, Cusumano F, Andreola S et al (1999) Reoperation for locally recurrent breast cancer in patients previously treated with conservative surgery. Br J Surg 86:84 87

40 * Resch A, Fellner C, Mock U, Handl-Zeller L, Biber E, Seitz W et al (2002) Locally recurrent breast cancer: pulse dose rate brachytherapy for repeat irradiation following lumpectomy a second chance to preserve the breast. Radiology 225:

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