乳腺癌保留乳房治疗后局部及远处失败的相关因素研究
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摘要
1986年5月～2000年11月间，天津医科大学肿瘤医院对原发女性乳腺癌行保乳治疗174例，复习全部病历、钼靶X光片及病理切片，回顾性研究术后局部及远处失败的相关因素。随访12～196个月，随访率97.13％(169／174)。结果：1．局部复发9例，3年复发率3.79％(5／132)：远处转移14例，5年转移率10.99％(10／91)；5年生存率92.31％(84／91)。2．保乳手术无放疗组3年复发率(12.12％)显著高于手术加放疗组(1.01％)，P＜0.025。3．腋淋巴结阳性患者中保乳手术未化疗组5年远处转移率(44.44％)高于手术加化疗组(6.67％)，P＜0.05。4．切缘阳性与局部复发有关(P=0.0013)。5．乳腺癌诊断时年龄≤40岁、淋巴结阳性、组织学Ⅲ级与远处转移有关(P＜0.05)。通过研究表明，保乳术后应放疗：切缘阳性者应再切除至阴性或全乳切除术；年轻、淋巴结阳性、组织学分级Ⅲ级者应辅助化疗。
Between May in 1986 and November in 2000, 174 patients with primary breast cancer were treated by breast-conserving therapy (BCT) in Tianjin Medical University Cancer Hospital. Their records, mammograms and pathological sections were reviewed. The purpose was to study the relative factors of local and distant failures after BCT retrospectively. The period of follow up was 12 to 196 months. The rate of follow up was 97.13%(169/174). Results: 1. There were 9 patients with local recurrence and 14 patients with distant metastasis. And 3-year recurrence rate was 3.79% (5/132);5-year metastasis rate was 10.99% (10/91); and 5-year survival rate was 92.31% (84/91). 2. 3-year recurrence rate for patients without radiotherapy (12.12%) was significantly higher than that with radiotherapy (1.01%), P<0.025. 3. In the group of patients with node-positive, 5 -year metastasis rate for patients without chemotherapy (44.44%) was higher than that with chemotherapy (6.67%), P<0.05. 4. Positive margin status was associated with
local recurrence (P=0.0013). 5. Age at diagnosis of Patient with breast cancer (<40 years ), node-positive , grade 3
histology were all highly significant factors of metastasis (p<0.05). The results showed that radiotherapy must be given after BCT; the patients with positive margin should be treated by reexcision or by mastectomy; the patients with young age,node-positive and grade 3 should receive adjuvant chemotherapy.
Between May in 1986 and November in 2000, 174 patients with primary breast cancer were treated by breast-conserving therapy (BCT) in Tianjin Medical University Cancer Hospital. Their records, mammograms and pathological sections were reviewed. The purpose was to study the relative factors of local and distant failures after BCT retrospectively. The period of follow up was 12 to 196 months. The rate of follow up was 97.13%(169/174). Results: 1. There were 9 patients with local recurrence and 14 patients with distant metastasis. And 3-year recurrence rate was 3.79% (5/132);5-year metastasis rate was 10.99% (10/91); and 5-year survival rate was 92.31% (84/91). 2. 3-year recurrence rate for patients without radiotherapy (12.12%) was significantly higher than that with radiotherapy (1.01%), P<0.025. 3. In the group of patients with node-positive, 5 -year metastasis rate for patients without chemotherapy (44.44%) was higher than that with chemotherapy (6.67%), P<0.05. 4. Positive margin status was associated with
local recurrence (P=0.0013). 5. Age at diagnosis of Patient with breast cancer (<40 years ), node-positive , grade 3
histology were all highly significant factors of metastasis (p<0.05). The results showed that radiotherapy must be given after BCT; the patients with positive margin should be treated by reexcision or by mastectomy; the patients with young age,node-positive and grade 3 should receive adjuvant chemotherapy.
引文
1．杨家祥，孙世良，向前，等。保存乳房式治疗乳腺癌20例临床总结。中国肿瘤临床，1995；22(1)：58
2．张斌，何文贵，蔡玉娥，等。保守性手术加放疗治疗早期乳腺癌。中国肿瘤杂志，1995；17(5)：368
3．李瑞英，王平，崔晓利。早期乳腺癌保留乳房的综合治疗。中国肿瘤临床，2000：27(9)：655
4. Paul P, Rosen, Patricia E, et al. Predictors of Recurrence in Stage I (T_1N_0M_0)Breast Carcinoma. Ann, Surg, 1981; 193(1):15
5. Roland Holland, Solke H, Marcel M, et. al. Histologic Multifocality of Tis, T_(1-2) Breast Carcinomas. Cancer, 1985; 56:979
6. John M, Robert A, Henri B, et al. Local Recurrence After Breast-Conserving Surgery and Radiotherapy. Cancer, 1989; 63:1912
7. David P, Winchester, James D, et al. Standards for Breast-Conservation Treatment. CA. 1992: 42(3):134
8. Allen S. Marc E, David N, et al. Mastectomy Versus Breast-Conserving Therapy in the Treatment of Stage Ⅰ and Ⅱ Carcinoma of the Breast: A Randomized Trial at the National Cancer Institute. J Clin Oncol, 1992; 10:976
9. Jonathan M, William C, Diana C. Determinants of Receiving Breast-Conserving Surgery. Cancer, 1994; 73:2344
10. Asa J, Danna N, Daniel F, et al. Relationship of Patient Age to Pathologic Features of the Tumor and Prognosis for Patients with Stage Ⅰ or Ⅱ Breast Cancer. J Clin Oncol, 1994; 12:888
11． Jacques B,Harry K,Augustinus H,et al.Risk Factors in Breast-Conservation Therapy.J Clin Oncol,1994;12:653
12． John A.Rodrigo A.Simone B,et al.Local Relapse and Contralateral Tumor Rates in Patients with Breast Cancer Treated with Conservative Surgery and Radiothrapy.Cancer.1995;76:2260
13． Melanie C.Smitt.The Importance of the Lumpectomy Surgical Margin in Long Term Results of Breast Conservation.Cancer.1995:76:259
14． Cowen D,Jacquemier J,Houvenaeghel G,et al.Local and Distant Recurrence After Conservative Management of "Very Low-Risk" Breast Cancer are Dependent Events:a 10-Year Follow-up.Int J Padiat Oncol Biol Phys,1998;41(4) :801
15． Harrold EV,Turner BC,Matloff ET,et al.Local Recurrence in the Conservatively Treated Breast Cancer Patients:a Correlation with Age and Family History.Cancer J Sci Am,1998;4(5) :302
16． Kollias J,Gill PG,Beancond B,et al.Clinical and Rediological Predictors of Complete Excision in Breast Conserving Surgery for Primary Breast Cancer.Aust NZ J Sury,1998:68(10) :702
17． Didier Cowen.Gilles H.Valerie-Jeanne B.et al.Local and Distant Failures after Limited Surgery with Positive Margins and Radiotherapy for Node-Negative Breast Cancer.Int J Rediat Oncol Biol phys.2000;47(2) :305
18． B.Salvadori,E.Marubini.R.Miceli.et al.Reoperation for Loeally Recurrent Breast Cancer in Patients Previously Treated with Conservative Surgery.British J of Surgery.1999;86:84
19． M.Francis.B.Cakir.O.Ung.et al.Prognosis after Breast Recurrence
Following Conservative Surgery and Rediotherapy in Patients with Node-Negative Breast Cancer.British J of Surgery,1999;86:1556
20． Andre Fortin,Marie L,Jacques L.et al.Local Failure is Responsible for the Decrease in Survival for Patients with Breast Cancer Treated with Conservative Surgery and Postoperative Radiothrapy.J Clin Oncol,1999;17:101
21． Fowble B.Hanlon A.Freedman G.et al.Postmenopausal Hormone Replacement Therapy:Effect on Diagnosis and Outcome in Early-Stage Invasive Breast Cancer Treated with Conservative Surgery and radiation.J Clin Oncol.1999;17(6) :1680
22． Hepp R,Baeza MR.Conservative Treatment of Ductal Carcinoma In Situ of the Breast.Rev Med chil.1999;127(11) :1345
23． Freedman G,Fowble B,Hanlon A,et al.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 Rediat Oncol Biol Phys,1999;44(5) :1005
24． Didier Cowen,Gilles H,Valerie-Jeanne B,et al.Local and Distant Failures After Limited Surgery with Positive Margins and Radiotherapy for Node-Negative Breast Cancer,Int J Radiat Oncol Biol Phys,2000;(47) 2:305
25． Anthony L,James L,Abram R,et al.The Relation Between the Presence and Extent of Lobular Carcinoma in Situ and the Risk of Local Recurrence for Patients with Infiltrating Carcinoma of the Breast Treated with Conservative Surgery and Radiation Therapy.Cancer.2000;88(5) :1072
26． Kestin LL.Goldstein NS.Martinez AA,et al.Mammographically Detected Ductal Carcinoma in Situ Treated with Conservative Surgerv with or without
Radiation Therapy:Patterns of Failure and 10-Year Results:Ann Sury,2000;231(2) :235
27． Ogawa Y,Nishioka A,Inomata T,et al.Conservation Treatment Intensified with an Anti-Estrogen Agent and CAF Chemotherapy for Stage Ⅰ and ⅡBreast Cancer.Oncol Rep,2000;7(3) :479
28． Aristei C.Marsclla AR.Chionne F,et al.Regional Node Failure in Patients with Four or More Postive Lymph Nodes Submitted to Conservative Surgen Followed by Radiotherapy to the Breast.Am J Clin Oncol,2000;23(3) :217
29． Obedian E.Haffty BG.Negative Margin Status Improves Local Control in Conservatively Managed Breast Cancer Patients.Cancer J Sci Am,2000;6(1) :28
30． I.S.Fentiman.Long-Term Follow-Up of the First Breast Conservation Trial:Guy's Wide Excision Study.The Breast,2000;9:5
31． Henri M.Franck P,Philippe B,et al.Low Body Mass Index is an Independent Predictive Factor of Local Recurrence after Conservative Treatment for Breast Cancer.Breast Cancer Research and Treatment,2001;66:17
32． Thomas A,Buchholz,Susan L,et al.Impact of systemic Treatment on Local Control for Patients with lymph Node-Negative Breast Cancer Treated with Breast-Conservation Therapy.J clin Oncol,2001;19:2240
33． Adri C.Maja N,Johannes L,et al.Differences in Risk Factors Local and Distant Recurrence After Breast-Conserving Therapy or Mastectomy for stage Ⅰand Ⅱ Breast Cancer:Pooled Results of Two Large European Randomized Trials.J Clin Oncol,2001;19:1688
34． Monica M.Julia W.Jennifer M,et al.Factors Predicting the Use of Breast-Conserving Therapy in Stage Ⅰ and Ⅱ Breast Carcinoma.J Clin Oncol.2001;
19:2254
35. Haagensen. Diseases of the Breast, Third Edition, 1986; 933
36．涂柳果，李继业，陈国雄，等。局部切除、腋窝淋巴结清扫加术后放疗治疗早期乳腺癌的近期效果。军医进修学院学报，1995：16(3)：187
37．孙敏，魏守杰，衣龙海，等。乳腺癌保留乳房治疗的临床研讨。中华外科杂志，1995：33(10)：606
38．于金明，李建彬，孙敏 等。乳腺癌保留乳房术后放射治疗58例。中华放射肿瘤学杂志，1997：6(1)：27
39．孙梅。乳腺癌保留乳房手术的探讨。齐鲁肿瘤杂志，2000：15(2)：101
40．李树玲。乳腺肿瘤学。北京。科学技术文献出版社，2000；101
2．张斌，何文贵，蔡玉娥，等。保守性手术加放疗治疗早期乳腺癌。中国肿瘤杂志，1995；17(5)：368
3．李瑞英，王平，崔晓利。早期乳腺癌保留乳房的综合治疗。中国肿瘤临床，2000：27(9)：655
4. Paul P, Rosen, Patricia E, et al. Predictors of Recurrence in Stage I (T_1N_0M_0)Breast Carcinoma. Ann, Surg, 1981; 193(1):15
5. Roland Holland, Solke H, Marcel M, et. al. Histologic Multifocality of Tis, T_(1-2) Breast Carcinomas. Cancer, 1985; 56:979
6. John M, Robert A, Henri B, et al. Local Recurrence After Breast-Conserving Surgery and Radiotherapy. Cancer, 1989; 63:1912
7. David P, Winchester, James D, et al. Standards for Breast-Conservation Treatment. CA. 1992: 42(3):134
8. Allen S. Marc E, David N, et al. Mastectomy Versus Breast-Conserving Therapy in the Treatment of Stage Ⅰ and Ⅱ Carcinoma of the Breast: A Randomized Trial at the National Cancer Institute. J Clin Oncol, 1992; 10:976
9. Jonathan M, William C, Diana C. Determinants of Receiving Breast-Conserving Surgery. Cancer, 1994; 73:2344
10. Asa J, Danna N, Daniel F, et al. Relationship of Patient Age to Pathologic Features of the Tumor and Prognosis for Patients with Stage Ⅰ or Ⅱ Breast Cancer. J Clin Oncol, 1994; 12:888
11． Jacques B,Harry K,Augustinus H,et al.Risk Factors in Breast-Conservation Therapy.J Clin Oncol,1994;12:653
12． John A.Rodrigo A.Simone B,et al.Local Relapse and Contralateral Tumor Rates in Patients with Breast Cancer Treated with Conservative Surgery and Radiothrapy.Cancer.1995;76:2260
13． Melanie C.Smitt.The Importance of the Lumpectomy Surgical Margin in Long Term Results of Breast Conservation.Cancer.1995:76:259
14． Cowen D,Jacquemier J,Houvenaeghel G,et al.Local and Distant Recurrence After Conservative Management of "Very Low-Risk" Breast Cancer are Dependent Events:a 10-Year Follow-up.Int J Padiat Oncol Biol Phys,1998;41(4) :801
15． Harrold EV,Turner BC,Matloff ET,et al.Local Recurrence in the Conservatively Treated Breast Cancer Patients:a Correlation with Age and Family History.Cancer J Sci Am,1998;4(5) :302
16． Kollias J,Gill PG,Beancond B,et al.Clinical and Rediological Predictors of Complete Excision in Breast Conserving Surgery for Primary Breast Cancer.Aust NZ J Sury,1998:68(10) :702
17． Didier Cowen.Gilles H.Valerie-Jeanne B.et al.Local and Distant Failures after Limited Surgery with Positive Margins and Radiotherapy for Node-Negative Breast Cancer.Int J Rediat Oncol Biol phys.2000;47(2) :305
18． B.Salvadori,E.Marubini.R.Miceli.et al.Reoperation for Loeally Recurrent Breast Cancer in Patients Previously Treated with Conservative Surgery.British J of Surgery.1999;86:84
19． M.Francis.B.Cakir.O.Ung.et al.Prognosis after Breast Recurrence
Following Conservative Surgery and Rediotherapy in Patients with Node-Negative Breast Cancer.British J of Surgery,1999;86:1556
20． Andre Fortin,Marie L,Jacques L.et al.Local Failure is Responsible for the Decrease in Survival for Patients with Breast Cancer Treated with Conservative Surgery and Postoperative Radiothrapy.J Clin Oncol,1999;17:101
21． Fowble B.Hanlon A.Freedman G.et al.Postmenopausal Hormone Replacement Therapy:Effect on Diagnosis and Outcome in Early-Stage Invasive Breast Cancer Treated with Conservative Surgery and radiation.J Clin Oncol.1999;17(6) :1680
22． Hepp R,Baeza MR.Conservative Treatment of Ductal Carcinoma In Situ of the Breast.Rev Med chil.1999;127(11) :1345
23． Freedman G,Fowble B,Hanlon A,et al.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 Rediat Oncol Biol Phys,1999;44(5) :1005
24． Didier Cowen,Gilles H,Valerie-Jeanne B,et al.Local and Distant Failures After Limited Surgery with Positive Margins and Radiotherapy for Node-Negative Breast Cancer,Int J Radiat Oncol Biol Phys,2000;(47) 2:305
25． Anthony L,James L,Abram R,et al.The Relation Between the Presence and Extent of Lobular Carcinoma in Situ and the Risk of Local Recurrence for Patients with Infiltrating Carcinoma of the Breast Treated with Conservative Surgery and Radiation Therapy.Cancer.2000;88(5) :1072
26． Kestin LL.Goldstein NS.Martinez AA,et al.Mammographically Detected Ductal Carcinoma in Situ Treated with Conservative Surgerv with or without
Radiation Therapy:Patterns of Failure and 10-Year Results:Ann Sury,2000;231(2) :235
27． Ogawa Y,Nishioka A,Inomata T,et al.Conservation Treatment Intensified with an Anti-Estrogen Agent and CAF Chemotherapy for Stage Ⅰ and ⅡBreast Cancer.Oncol Rep,2000;7(3) :479
28． Aristei C.Marsclla AR.Chionne F,et al.Regional Node Failure in Patients with Four or More Postive Lymph Nodes Submitted to Conservative Surgen Followed by Radiotherapy to the Breast.Am J Clin Oncol,2000;23(3) :217
29． Obedian E.Haffty BG.Negative Margin Status Improves Local Control in Conservatively Managed Breast Cancer Patients.Cancer J Sci Am,2000;6(1) :28
30． I.S.Fentiman.Long-Term Follow-Up of the First Breast Conservation Trial:Guy's Wide Excision Study.The Breast,2000;9:5
31． Henri M.Franck P,Philippe B,et al.Low Body Mass Index is an Independent Predictive Factor of Local Recurrence after Conservative Treatment for Breast Cancer.Breast Cancer Research and Treatment,2001;66:17
32． Thomas A,Buchholz,Susan L,et al.Impact of systemic Treatment on Local Control for Patients with lymph Node-Negative Breast Cancer Treated with Breast-Conservation Therapy.J clin Oncol,2001;19:2240
33． Adri C.Maja N,Johannes L,et al.Differences in Risk Factors Local and Distant Recurrence After Breast-Conserving Therapy or Mastectomy for stage Ⅰand Ⅱ Breast Cancer:Pooled Results of Two Large European Randomized Trials.J Clin Oncol,2001;19:1688
34． Monica M.Julia W.Jennifer M,et al.Factors Predicting the Use of Breast-Conserving Therapy in Stage Ⅰ and Ⅱ Breast Carcinoma.J Clin Oncol.2001;
19:2254
35. Haagensen. Diseases of the Breast, Third Edition, 1986; 933
36．涂柳果，李继业，陈国雄，等。局部切除、腋窝淋巴结清扫加术后放疗治疗早期乳腺癌的近期效果。军医进修学院学报，1995：16(3)：187
37．孙敏，魏守杰，衣龙海，等。乳腺癌保留乳房治疗的临床研讨。中华外科杂志，1995：33(10)：606
38．于金明，李建彬，孙敏 等。乳腺癌保留乳房术后放射治疗58例。中华放射肿瘤学杂志，1997：6(1)：27
39．孙梅。乳腺癌保留乳房手术的探讨。齐鲁肿瘤杂志，2000：15(2)：101
40．李树玲。乳腺肿瘤学。北京。科学技术文献出版社，2000；101