精准医学时代乳腺癌术后放疗的加减法
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摘要
放疗在乳腺癌治疗中扮演着重要角色,可使乳腺癌患者的局部复发率大大降低。近年来,临床试验结果显示,不同分子分型、淋巴结转移情况和手术切除方式的乳腺癌患者对放疗的临床获益有明显差异。因此,在精准医学时代,乳腺癌的放疗需要结合临床治疗指南及临床证据,并联系实际情况进行。根据患者个体的复发风险评估结果进行乳腺癌精准放疗可以使患者获益最大化,即降低复发率且不过度治疗。本文从肿瘤分子分型、淋巴结转移和手术切除方式3个方面总结了目前乳腺癌术后放疗的研究进展,以期为乳腺癌术后精准放疗提供临床依据。
Radiotherapy plays an important role in the current treatment of breast cancer, which can greatly reduce the local recurrence rate of breast cancer patients. In recent years, many clinical trials on the radiotherapy of breast cancer have shown that the benefits of radiotherapy are different in breast cancer patients with different molecular typing, lymph node metastasis, surgical resection methods, and so on. Therefore, in the era of precision medicine, the radiotherapy of breast cancer needs to be based on the clinical treatment guidelines and clinical evidence, and in combined with the actual situation. The precise radiotherapy should be carried out according to the assessment results of individual recurrence risk, so as to maximize the benefit of patients through reducing the recurrence rate and avoiding excessive treatment. In this paper, the current research progress in the post-operative radiotherapy based on the molecular classification of breast cancer, lymph node metastasis and surgical resection methods is summarized, in order to provide the clinical basis of postoperative precise radiotherapy for breast cancer patients.
Radiotherapy plays an important role in the current treatment of breast cancer, which can greatly reduce the local recurrence rate of breast cancer patients. In recent years, many clinical trials on the radiotherapy of breast cancer have shown that the benefits of radiotherapy are different in breast cancer patients with different molecular typing, lymph node metastasis, surgical resection methods, and so on. Therefore, in the era of precision medicine, the radiotherapy of breast cancer needs to be based on the clinical treatment guidelines and clinical evidence, and in combined with the actual situation. The precise radiotherapy should be carried out according to the assessment results of individual recurrence risk, so as to maximize the benefit of patients through reducing the recurrence rate and avoiding excessive treatment. In this paper, the current research progress in the post-operative radiotherapy based on the molecular classification of breast cancer, lymph node metastasis and surgical resection methods is summarized, in order to provide the clinical basis of postoperative precise radiotherapy for breast cancer patients.
引文
[1]LAURBERG T,TRAMM T,NIELSEN T,et al.Intrinsic subtypes and benefit from postmastectomy radiotherapy in node-positive premenopausal breast cancer patients who received adjuvant chemotherapy-results from two independent randomized trials[J].Acta Oncol,2018,57(1):38-43.
[2]ZETTERLUND L,CELEBIOGLU F,AXELSSON R,et al.Swedish prospective multicenter trial on the accuracy and clinical relevance of sentinel lymph node biopsy before neoadjuvant systemic therapy in breast cancer[J].Breast Cancer Res Treat,2017,163(1):93-101.
[3]LI H,XU D,HAN X,et al.Dosimetry study of 18F-FMISO+PET/CT hypoxia imaging guidance on intensitymodulated radiation therapy for nonsmall cell lung cancer[J].Clin Transl Oncol,2018,20(10):1329-1336.
[4]ZHANG Y,L I J,DUAN Y,et a l.Comparison of biological target volume metrics based on FDG PETCTand 4DCT for primary non-smallcell lung cancer[J].Oncotarget,2017,8(45):79629-79635.
[5]MAPELLI P,BROGGI S,INCERTI E,et al.FDG-PET/CT predicts outcome in oropharingeal carcinoma patients undergoing intensity modulated radiation therapy with dose escalation to FDG-avid tumour volumes[J].Curr Radiopharm,2017,10(2):102-110.
[6]SJTRM,LUNDSTEDT D,HARTMAN L,et al.Response to radiotherapy after breast-conserving surgery in different breast cancer subtypes in the Swedish Breast Cancer Group 91 Radiotherapy randomized clinical trial[J].J Clin Oncol,2017,35(28):3222-3229.
[7]SHAO M,ZHANG C,QIN Q,et al.The curative effects of radiotherapy-based therapies for human epidermal growth factor receptor 2-positive breast cancer:A meta-analysis[J].Medicine(Baltimore),2017,96(38):e7946.
[8]O’RORKE MA,MURRAY LJ,BRAND JS,et al.The value of adjuvant radiotherapy on survival and recurrence in triplenegative breast cancer:A systematic review and meta-analysis of 5 507patients[J].Cancer Treat Rev,2016,47:12-21.
[9]PAN XB,QU S,JIANG YM,et al.Triple negative breast cancer versus nontriple negative breast cancer treated with breast conservation surgery followed by radiotherapy:A systematic review and Meta-analysis[J].Breast Care(Basel),2015,10(6):413-416.
[10]GINGRAS I,HOLMES E,DE AZAMBUJA E,et al.Regional nodal irradiation after breast conserving surgery for early HER2-positive breast cancer:Results of a subanalysis from the ALTTOtrial[J].J Natl Cancer Inst,2017,109(8):djw331.
[11]KHALIFA J,DUPREZ-PAUMIER R,FILLERON T,et al.Outcome of pN0triple-negative breast cancer with or without lymph node irradiation:Asingle institution experience[J].Breast J,2016,22(5):510-519.
[12]STAUDER MC,CAUDLE AS,ALLEN PK,et al.Outcomes of post mastectomy radiation therapy in patients receiving axillary lymph node dissection after positive sentinel lymph node biopsy[J].Int J Radiat Oncol Biol Phys,2016,96(3):637-644.
[13]WHELAN TJ,OLIVOTTO IA,PARULEKARWR,et al.Regional nodal irradiation in early-stage breast cancer[J].N Engl JMed,2015,373(4):307-316.
[14]POORTMANS PM,COLLETTE S,KIRKOVE C,et al.Internal mammary and medial supraclavicular irradiation in breast cancer[J].N Engl J Med,2015,373(4):317-327.
[15]GIULIANO AE,BALLMAN KV,MCCALL L,et al.Effect of axillary dissection vs no axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis:the ACOSOG Z0011(Alliance)randomized clinical trial[J].JAMA,2017,318(10):918-926.
[16]BONNEAU C,HEQUET D,ESTEVEZ JP,et al.Impact of axillary dissection in women with invasive breast cancer who do not fit the Z0011 ACOSOG trial because of three or more metastatic sentinel lymph nodes[J].Eur J Surg Oncol,2015,41(8):998-1004.
[17]ZHAO M,LIU W G,ZHANG L,et al.Can axillary radiotherapy replace axillary dissection for patients with positive sentinel nodes?A systematic review and meta-analysis[J].Chronic Dis Transl Med,2017,3(1):41-50.
[18]DONKER M,VAN TIENHOVEN G,STRAVER ME,et al.Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer(EORTC 10981-22023 AMAROS):Arandomised,multicentre,open-label,phase 3 non-inferiority trial[J].Lancet Oncol,2014,15(12):1303-1310.
[19]HEADON H,KASEM A,ALMUKBEL R,et al.Improvement of survival with postmastectomy radiotherapy in patients with 1-3 positive axillary lymph nodes:A systematic review and meta-analysis of the current literature[J].Mol Clin Oncol,2016,5(4):429-436.
[20]YOON H I,YOON J,CHUNG Y,et al.Individual case review in a phase 3randomized trial to investigate the role of internal mammary lymph node irradiation for breast cancer:Korean Radiation Oncology Group 08-06study[J].Radiother Oncol,2017,123(1):15-21.
[21]CHOI J,KIM YB,SHIN KH,et al.Radiation pneumonitis in association with internal mammary node irradiation in breast cancer patients:An ancillary result from the KROG08-06 study[J].J Breast Cancer,2016,19(3):275-282.
[22]KIM KH,NOH JM,KIM YB,et al.Does internal mammary node irradiation affect treatment out come in clinical stageⅡ-Ⅲbreast cancer patients receiving neoadjuvant chemotherapy?[J].Breast Cancer Res Treat,2015,152(3):589-599.
[23]THORSEN LB,OFFERSEN BV,DANO H,et al.DBCG-IMN:A population-based cohort study on the effect of internal mammary node irradiation in early node-positive breast cancer[J].J Clin Oncol,2016,34(4):314-320.
[24]XUE C,PENG RJ,WANG SS,et al.Operable breast cancer of the inner hemisphere is associated with poor survival[J].J Breast Cancer,2015,18(1):36-43.
[25]TAM MM,WU SP,PEREZ C,et al.The effect of post-mastectomy radiation in women with one to three positive nodes enrolled on the control arm of BCIRG-005 at ten year follow-up[J].Radiother Oncol,2017,123(1):10-14.
[26]SáVOLTá,PéLEY G,POLGáR C,et al.Eightyear follow up result of the OTOASORtrial:The Optimal Treatment Of the Axilla-Surgery Or Radiotherapy after positive sentinel lymph node biopsy in early-stage breast cancer:A randomized,single centre,phaseⅢ,non-inferiority trial[J].Eur J Surg Oncol,2017,43(4):672-679.
[27]Killander F,Karlsson P,Anderson H,et al.No breast cancer subgroup can be spared postoperative radiotherapy after breast-conserving surgery.Fifteen-year results from the Swedish Breast Cancer Group randomised trial,SweBCG 91 RT[J].Eur J Cancer,2016,67:57-65.
[28]MARTELLI G,BORACCHI P,GUZZETTI E,et al.Omission of radiotherapy in elderly patients with early breast cancer:15-Year results of a prospective nonrandomised trial[J].Eur J Cancer,2015,51(11):1358-1364.
[29]VRIELING C,VAN WERKHOVEN E,MAINGON P,et al.Prognostic factors for local control in breast cancer after long-term follow-up in the EORTCboost vs no boost trial:A randomized clinical trial[J].JAMA Oncol,2017,3(1):42-48.
[30]BARTELINK H,MAINGON P,POORTMANS P,et al.Whole-breast irradiation with or without a boost for patients treated with breastconserving surgery for early breast cancer:20-year follow-up of a randomised phase 3 trial[J].Lancet Oncol,2015,16(1):47-56.
[31]PAELINCK L,GULYBAN A,LAKOSI F,et al.Does an integrated boost increase acute toxicity in prone hypofractionated breast irradiation?A randomized controlled trial[J].Radiother Oncol,2017,122(1):30-36.
[32]SATO K,MIZUNO Y,FUCHIKAMI H,et al.Impact of young age on local control after partial breast irradiation in Japanese patients with early stage breast cancer[J].Breast Cancer,2017,24(1):79-85.
[33]MEATTINI I,SAIEVA C,MICCINESI G,et al.Accelerated partial breast irradiation using intensity modulated radiotherapy versus whole breast irradiation:Health-related quality of life final analysis from the Florence phase 3 trial[J].Eur J Cancer,2017,76:17-26.
[34]ARISTEI C,MARANZANO E,LANCELLOTTA V,et al.Partial breast irradiation with interstitial multi-catheter high-doserate brachytherapy:Long-term results of a phaseⅡprospective study[J].Radiother Oncol,2017,124(2):208-213.
[35]WHITE J,WINTER K,KUSKE RR,et al.Long-term cancer outcomes from Study NRG Oncology/RTOG 9517:Aphase 2 study of accelerated partial breast irradiation with multicatheter brachytherapy after lumpectomy for early-stage breast cancer[J].Int J Radiat Oncol Biol Phys,2016,95(5):1460-1465.
[36]STRNAD V,OTT OJ,HILDEBRANDT G,et al.5-year results of accelerated partial breast irradiation using sole interstitial multicatheter brachytherapy versus whole-breast irradiation with boost after breast-conserving surgery for low-risk invasive and in-situ carcinoma of the female breast:Arandomised,phase 3,non-inferiority trial[J].Lancet,2016,387(10015):229-238.
[37]OTT OJ,STRNAD V,HILDEBRANDT G,et al.GEC-ESTRO multicenter phase 3-trial:Accelerated partial breast irradiation with interstitial multicat heter brachytherapy versus external beam whole breast irradiation:Early toxicity and patient compliance[J].Radiother Oncol,2016,120(1):119-123.
[38]NOSE T,OTANI Y,ASAHI S,et al.A Japanese prospective mul t iinstitutional feasibility study on accelerated partial breast irradiation using interstitial brachytherapy:Clinical results with a median followup of 26 months[J].Breast Cancer,2016,23(6):861-868.
[39]HORST KC,FASOLA C,IKEDA D,et al.Five-year results of a prospective clinical trial investigating accelerated partial breast irradiation using3D conformal radiotherapy after lumpectomy for early stage breast cancer[J].Breast,2016,28:178-183.
[40]POLGáR C,OTT O J,HILDEBRANDT G,et al.Late side-effects and cosmetic results of accelerate dpartial breast irradiation with interstitial brachytherapy versus whole-breast irradiation after breast-conserving surgery for low-risk invasive and insitu carcinoma of the female breast:5-year results of a randomised,controlled,phase 3 trial[J].Lancet Oncol,2017,18(2):259-268.
[41]KONG L,CHENG J,DING X,et al.Efficacy and safety of accelerated partial breast irradiation after breastconserving surgery:A meta-analysis of published comparative studies[J].Breast J,2014,20(2):116-124.
[42]WNBERG F,GARMO H,EMDIN S,et al.Effect of radiotherapy after breast-conserving surgery for ductal carcinoma in situ:20 years follow-up in the randomized SweDCIS Trial[J].JClin Oncol,2014,32(32):3613-3618.
[43]MCCORMICK B,WINTER K,HUDIS C,et al.RTOG 9804:A prospective randomized trial for good-risk ductal carcinoma in situ comparing radiotherapy with observation[J].J Clin Oncol,2015,33(7):709-715.
[44]KRUG D,SOUCHON R.Omission of adjuvant radiotherapy in ductal carcinoma in situ:12 year-results of the ECOG-ACRINE 5194-trial[J].Strahlenther Onkol,2016,192(5):349-351.
[45]GARG PK,JAKHETIYA A,PANDEY R,et al.Adjuvant radiotherapy versus observation following lumpectomy in ductal carcinoma in-situ:Ameta-an alysis of randomized controlled trials[J].Breast J,2018,24(3):233-239.
[46]顾健人.癌症精准医学[J].肿瘤,2016,36(1):1-2.
[2]ZETTERLUND L,CELEBIOGLU F,AXELSSON R,et al.Swedish prospective multicenter trial on the accuracy and clinical relevance of sentinel lymph node biopsy before neoadjuvant systemic therapy in breast cancer[J].Breast Cancer Res Treat,2017,163(1):93-101.
[3]LI H,XU D,HAN X,et al.Dosimetry study of 18F-FMISO+PET/CT hypoxia imaging guidance on intensitymodulated radiation therapy for nonsmall cell lung cancer[J].Clin Transl Oncol,2018,20(10):1329-1336.
[4]ZHANG Y,L I J,DUAN Y,et a l.Comparison of biological target volume metrics based on FDG PETCTand 4DCT for primary non-smallcell lung cancer[J].Oncotarget,2017,8(45):79629-79635.
[5]MAPELLI P,BROGGI S,INCERTI E,et al.FDG-PET/CT predicts outcome in oropharingeal carcinoma patients undergoing intensity modulated radiation therapy with dose escalation to FDG-avid tumour volumes[J].Curr Radiopharm,2017,10(2):102-110.
[6]SJTRM,LUNDSTEDT D,HARTMAN L,et al.Response to radiotherapy after breast-conserving surgery in different breast cancer subtypes in the Swedish Breast Cancer Group 91 Radiotherapy randomized clinical trial[J].J Clin Oncol,2017,35(28):3222-3229.
[7]SHAO M,ZHANG C,QIN Q,et al.The curative effects of radiotherapy-based therapies for human epidermal growth factor receptor 2-positive breast cancer:A meta-analysis[J].Medicine(Baltimore),2017,96(38):e7946.
[8]O’RORKE MA,MURRAY LJ,BRAND JS,et al.The value of adjuvant radiotherapy on survival and recurrence in triplenegative breast cancer:A systematic review and meta-analysis of 5 507patients[J].Cancer Treat Rev,2016,47:12-21.
[9]PAN XB,QU S,JIANG YM,et al.Triple negative breast cancer versus nontriple negative breast cancer treated with breast conservation surgery followed by radiotherapy:A systematic review and Meta-analysis[J].Breast Care(Basel),2015,10(6):413-416.
[10]GINGRAS I,HOLMES E,DE AZAMBUJA E,et al.Regional nodal irradiation after breast conserving surgery for early HER2-positive breast cancer:Results of a subanalysis from the ALTTOtrial[J].J Natl Cancer Inst,2017,109(8):djw331.
[11]KHALIFA J,DUPREZ-PAUMIER R,FILLERON T,et al.Outcome of pN0triple-negative breast cancer with or without lymph node irradiation:Asingle institution experience[J].Breast J,2016,22(5):510-519.
[12]STAUDER MC,CAUDLE AS,ALLEN PK,et al.Outcomes of post mastectomy radiation therapy in patients receiving axillary lymph node dissection after positive sentinel lymph node biopsy[J].Int J Radiat Oncol Biol Phys,2016,96(3):637-644.
[13]WHELAN TJ,OLIVOTTO IA,PARULEKARWR,et al.Regional nodal irradiation in early-stage breast cancer[J].N Engl JMed,2015,373(4):307-316.
[14]POORTMANS PM,COLLETTE S,KIRKOVE C,et al.Internal mammary and medial supraclavicular irradiation in breast cancer[J].N Engl J Med,2015,373(4):317-327.
[15]GIULIANO AE,BALLMAN KV,MCCALL L,et al.Effect of axillary dissection vs no axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis:the ACOSOG Z0011(Alliance)randomized clinical trial[J].JAMA,2017,318(10):918-926.
[16]BONNEAU C,HEQUET D,ESTEVEZ JP,et al.Impact of axillary dissection in women with invasive breast cancer who do not fit the Z0011 ACOSOG trial because of three or more metastatic sentinel lymph nodes[J].Eur J Surg Oncol,2015,41(8):998-1004.
[17]ZHAO M,LIU W G,ZHANG L,et al.Can axillary radiotherapy replace axillary dissection for patients with positive sentinel nodes?A systematic review and meta-analysis[J].Chronic Dis Transl Med,2017,3(1):41-50.
[18]DONKER M,VAN TIENHOVEN G,STRAVER ME,et al.Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer(EORTC 10981-22023 AMAROS):Arandomised,multicentre,open-label,phase 3 non-inferiority trial[J].Lancet Oncol,2014,15(12):1303-1310.
[19]HEADON H,KASEM A,ALMUKBEL R,et al.Improvement of survival with postmastectomy radiotherapy in patients with 1-3 positive axillary lymph nodes:A systematic review and meta-analysis of the current literature[J].Mol Clin Oncol,2016,5(4):429-436.
[20]YOON H I,YOON J,CHUNG Y,et al.Individual case review in a phase 3randomized trial to investigate the role of internal mammary lymph node irradiation for breast cancer:Korean Radiation Oncology Group 08-06study[J].Radiother Oncol,2017,123(1):15-21.
[21]CHOI J,KIM YB,SHIN KH,et al.Radiation pneumonitis in association with internal mammary node irradiation in breast cancer patients:An ancillary result from the KROG08-06 study[J].J Breast Cancer,2016,19(3):275-282.
[22]KIM KH,NOH JM,KIM YB,et al.Does internal mammary node irradiation affect treatment out come in clinical stageⅡ-Ⅲbreast cancer patients receiving neoadjuvant chemotherapy?[J].Breast Cancer Res Treat,2015,152(3):589-599.
[23]THORSEN LB,OFFERSEN BV,DANO H,et al.DBCG-IMN:A population-based cohort study on the effect of internal mammary node irradiation in early node-positive breast cancer[J].J Clin Oncol,2016,34(4):314-320.
[24]XUE C,PENG RJ,WANG SS,et al.Operable breast cancer of the inner hemisphere is associated with poor survival[J].J Breast Cancer,2015,18(1):36-43.
[25]TAM MM,WU SP,PEREZ C,et al.The effect of post-mastectomy radiation in women with one to three positive nodes enrolled on the control arm of BCIRG-005 at ten year follow-up[J].Radiother Oncol,2017,123(1):10-14.
[26]SáVOLTá,PéLEY G,POLGáR C,et al.Eightyear follow up result of the OTOASORtrial:The Optimal Treatment Of the Axilla-Surgery Or Radiotherapy after positive sentinel lymph node biopsy in early-stage breast cancer:A randomized,single centre,phaseⅢ,non-inferiority trial[J].Eur J Surg Oncol,2017,43(4):672-679.
[27]Killander F,Karlsson P,Anderson H,et al.No breast cancer subgroup can be spared postoperative radiotherapy after breast-conserving surgery.Fifteen-year results from the Swedish Breast Cancer Group randomised trial,SweBCG 91 RT[J].Eur J Cancer,2016,67:57-65.
[28]MARTELLI G,BORACCHI P,GUZZETTI E,et al.Omission of radiotherapy in elderly patients with early breast cancer:15-Year results of a prospective nonrandomised trial[J].Eur J Cancer,2015,51(11):1358-1364.
[29]VRIELING C,VAN WERKHOVEN E,MAINGON P,et al.Prognostic factors for local control in breast cancer after long-term follow-up in the EORTCboost vs no boost trial:A randomized clinical trial[J].JAMA Oncol,2017,3(1):42-48.
[30]BARTELINK H,MAINGON P,POORTMANS P,et al.Whole-breast irradiation with or without a boost for patients treated with breastconserving surgery for early breast cancer:20-year follow-up of a randomised phase 3 trial[J].Lancet Oncol,2015,16(1):47-56.
[31]PAELINCK L,GULYBAN A,LAKOSI F,et al.Does an integrated boost increase acute toxicity in prone hypofractionated breast irradiation?A randomized controlled trial[J].Radiother Oncol,2017,122(1):30-36.
[32]SATO K,MIZUNO Y,FUCHIKAMI H,et al.Impact of young age on local control after partial breast irradiation in Japanese patients with early stage breast cancer[J].Breast Cancer,2017,24(1):79-85.
[33]MEATTINI I,SAIEVA C,MICCINESI G,et al.Accelerated partial breast irradiation using intensity modulated radiotherapy versus whole breast irradiation:Health-related quality of life final analysis from the Florence phase 3 trial[J].Eur J Cancer,2017,76:17-26.
[34]ARISTEI C,MARANZANO E,LANCELLOTTA V,et al.Partial breast irradiation with interstitial multi-catheter high-doserate brachytherapy:Long-term results of a phaseⅡprospective study[J].Radiother Oncol,2017,124(2):208-213.
[35]WHITE J,WINTER K,KUSKE RR,et al.Long-term cancer outcomes from Study NRG Oncology/RTOG 9517:Aphase 2 study of accelerated partial breast irradiation with multicatheter brachytherapy after lumpectomy for early-stage breast cancer[J].Int J Radiat Oncol Biol Phys,2016,95(5):1460-1465.
[36]STRNAD V,OTT OJ,HILDEBRANDT G,et al.5-year results of accelerated partial breast irradiation using sole interstitial multicatheter brachytherapy versus whole-breast irradiation with boost after breast-conserving surgery for low-risk invasive and in-situ carcinoma of the female breast:Arandomised,phase 3,non-inferiority trial[J].Lancet,2016,387(10015):229-238.
[37]OTT OJ,STRNAD V,HILDEBRANDT G,et al.GEC-ESTRO multicenter phase 3-trial:Accelerated partial breast irradiation with interstitial multicat heter brachytherapy versus external beam whole breast irradiation:Early toxicity and patient compliance[J].Radiother Oncol,2016,120(1):119-123.
[38]NOSE T,OTANI Y,ASAHI S,et al.A Japanese prospective mul t iinstitutional feasibility study on accelerated partial breast irradiation using interstitial brachytherapy:Clinical results with a median followup of 26 months[J].Breast Cancer,2016,23(6):861-868.
[39]HORST KC,FASOLA C,IKEDA D,et al.Five-year results of a prospective clinical trial investigating accelerated partial breast irradiation using3D conformal radiotherapy after lumpectomy for early stage breast cancer[J].Breast,2016,28:178-183.
[40]POLGáR C,OTT O J,HILDEBRANDT G,et al.Late side-effects and cosmetic results of accelerate dpartial breast irradiation with interstitial brachytherapy versus whole-breast irradiation after breast-conserving surgery for low-risk invasive and insitu carcinoma of the female breast:5-year results of a randomised,controlled,phase 3 trial[J].Lancet Oncol,2017,18(2):259-268.
[41]KONG L,CHENG J,DING X,et al.Efficacy and safety of accelerated partial breast irradiation after breastconserving surgery:A meta-analysis of published comparative studies[J].Breast J,2014,20(2):116-124.
[42]WNBERG F,GARMO H,EMDIN S,et al.Effect of radiotherapy after breast-conserving surgery for ductal carcinoma in situ:20 years follow-up in the randomized SweDCIS Trial[J].JClin Oncol,2014,32(32):3613-3618.
[43]MCCORMICK B,WINTER K,HUDIS C,et al.RTOG 9804:A prospective randomized trial for good-risk ductal carcinoma in situ comparing radiotherapy with observation[J].J Clin Oncol,2015,33(7):709-715.
[44]KRUG D,SOUCHON R.Omission of adjuvant radiotherapy in ductal carcinoma in situ:12 year-results of the ECOG-ACRINE 5194-trial[J].Strahlenther Onkol,2016,192(5):349-351.
[45]GARG PK,JAKHETIYA A,PANDEY R,et al.Adjuvant radiotherapy versus observation following lumpectomy in ductal carcinoma in-situ:Ameta-an alysis of randomized controlled trials[J].Breast J,2018,24(3):233-239.
[46]顾健人.癌症精准医学[J].肿瘤,2016,36(1):1-2.