放射治疗在早期乳腺癌中的应用

目前在早期乳腺癌的治疗中，保乳治疗（breast—conserving therapy）已经被广泛认为是一种安全而有效的治疗方法。过去20年中进行的大量临床试验表明：对于Ⅰ～Ⅱ期乳腺癌患者，采用保乳手术加术后放射治疗的方案已经成为标准的治疗方案；其总生存率及无病生存率均与乳腺癌根治术相等。保乳治疗的步骤主要包括：（1）原发肿瘤局部切除，切缘阴性；     

Edema of the arm as a function of the extent of axillary surgery in patients with stage I-II carcinoma of the breast treated with primary radiotherapy

Edema of the arm can be a significant complication following treatment of breast cancer. To determine the risk of arm edema and factors associated with this risk in patients treated with primary radiotherapy, we reviewed the records of 475 women with early breast cancer treated between 1968 and 1980. During this period, the use of axillary surgery prior to radiation gradually increased, and all patients received full axillary irradiation until late in the series. Based on the surgeon's report, the extent of axillary surgery was classified as either a sampling, a lower dissection, or a full dissection. Edema of the arm was scored on clinical grounds and ranged from mild hand swelling to an increased arm circumference of 8 cm. At 6 years, the actuarial risk of developing arm edema was 8% for the entire study population. This risk was 13% for 240 patients who had axillary surgery and 4% for 235 patients not undergoing axillary surgery (p = 0.006). For patients undergoing axillary surgery, the risk of arm edema was 37% with full dissection compared to 5% with sampling (p = 0.0003), and 8% with lower dissection (p = 0.03). The risk of arm edema at 6 years was 28% if more than ten nodes were removed, and 9% if one to ten nodes were removed (p = 0.03). However, the extent of axillary dissection was stronger predictor of subsequent edema than was the number of nodes obtained. The role of axillary irradiation could not be evaluated since 91% of patients received axillary irradiation. The use of chemotherapy, the site or size of the primary tumor, clinical nodal status, patient age and weight, type of suture, the use of a drain, and subsequent local or distant failure did not appear to be significant risk factors. We conclude that the combination of full dissection and full axillary irradiation results in an unacceptably high risk of arm edema.     

Survival of women after breast conserving surgery for early stage breast cancer

Background. Increasing numbers of older women with breast cancer are receiving breast-conserving surgery (BCS). However, substantial numbers of them are not receiving either axillary dissection or adjuvant irradiation. Objective. To determine whether failure to perform axillary dissection or irradiation is associated with decreased survival in women with early-stage breast cancer. Method. We studied 26,290 women aged 25 in 1988-1993 from the surveillance, epidemiology, and end results (SEER) data and 5,328 women aged 65 in 1991-1993 from SEER-Medicare linked data, who had early-stage breast cancer and received BCS. Results. Twenty seven percent of women aged 25 receiving BCS did not receive axillary dissection, most of whom (74%) were age 65. Women receiving BCS with axillary dissection had lower 7-year breast cancer-specific mortality than did those without dissection (hazard ratio=0.53, 95% confidence interval: 0.44–0.63). We found an interaction between receipt of axillary dissection and radiotherapy on survival of older women after BCS. Women who received either axillary dissection or radiotherapy experienced similar survivals to those who received both axillary dissection and radiation, while women who received neither treatment experienced poorer survival (hazard ratio=1.76, 1.23–2.52), after controlling for demographics, tumor size and comorbidity. Conclusions. Women who receive neither axillary dissection nor radiation therapy after BCS experience an increased risk of death from breast cancer. The lack of improvement in the past two decades in survival of older women with breast cancer may be explained in part by the increasing use of treatments that do not address potential tumor in axillary nodes.     

放射治疗在早期乳腺癌保乳术中的价值

目的：进一步证实放射治疗在早期乳腺癌保乳术中的重要性。方法：1994年12月～2001年12月本院共收治237例早期乳腺癌。其中83例做保乳手术。154例做改良根治术。保乳术后全部患者接受放疗。放疗的范围根据肿块的大小、部位、腋淋巴结是否受累而定。胸壁切线剂量予8MV—X线5000cGy。肿瘤瘤床加电子线1500cGy。改良根治术后仅3例作放疗。结果：保乳组和改良组局部复发各1人。保乳组区域淋巴结复发1例。改良组无区域淋巴结复发，有肝转移、肺转移各1人。两组各死亡1人。保乳组五年生存率96．49％，改良组98．61％。保乳组双侧乳房外形基本一致，柔软，有弹性。结论：早期乳腺癌保乳术加放射治疗，效果与改良根治术相似，并伴良好美容效果。     

早期乳腺癌保留乳房手术后放射治疗的临床分析

乳腺癌是一种以局部表现为主的全身性疾病，扩大切除术并不一定能改善预后，因此，保留乳房手术后辅以放射治疗逐渐成为早期乳腺癌的主要治疗方向。现将本院使用保留乳房手术加术后放射治疗早期乳腺癌总结如下。     

早期乳腺癌保乳术后放化疗的最佳顺序

目的 探讨早期乳腺癌保乳治疗后放化疗最佳顺序，使保乳治疗的局部控制、远处转移和保乳效果达到最佳。方法 2000年1月～2002年11月，对38例符合保乳治疗条件的早期乳腺癌实施了保乳治疗。手术方式为局部广泛切除术和腋窝淋巴结清扫，术后2周开始化疗，化疗2周期后再开始放疗，全乳剂量50Gy，瘤床补充照射10～18Gy。放疗结束后根据使用化疗方案选择立即化疗或休息1周后再开始化疗，化疗共6周期。治疗结束后每3个月复查1次，放疗后6个月行乳房钼靶摄影。此后1年1次乳房照片检查。结果 38例保乳治疗的患者均定期复查，中位随访24个月(5～35个月)。未发现局部复发和远处转移。放疗后1年或以上的28例患者乳房外观良好。结论 早期乳腺癌保乳治疗中“三明治”式放化疗能满足保乳治疗的目的。     

早期乳腺癌根治术后放射治疗靶区的确定

目的：确定早期乳腺癌根治术后放射治疗的靶区。方法：回顾分析本院行乳腺切除和腋窝淋巴结清扫的605例T1－2N0－1M0期乳腺癌患者。所有得接受乳腺癌根治术,343例接受术后放射治疗,其中,135例接受胸壁放射治疗,270例锁骨上腋顶放射治疗,98例腋窝放射治疗,340例内乳放射治疗。生存分析采用Kaplan-Meier法,局部区域复发率的差别用Logrank检验。结果：全组患者的10年胸壁复发率为5．2％,10年锁骨上淋巴结复发率为6．5％,10年腋窝淋巴结复发率为2．9％,10年内乳淋巴结复发率为0．2％。未做胸壁放射治疗时,腋窝淋巴结转移数为0,1－3和≥4个的10年胸壁复发率分别为4．9％,5．3％和11．8％,腋窝淋巴结转移数≥4个的复发率比腋窝淋巴结转移数为0和1－3个有增高的趋势（P＝0．062）,放射治疗有降低这组患者胸壁复发率的趋势（2．9％和11．8％,P＝0．089）,未做锁骨上放射治疗时,腋窝淋巴结转移数≥4个的10年锁骨上复发率明显高于腋窝淋巴结转移数为0和1－3个者（42．4％和3．1％和9．1％,P＝0．000）,放射治疗可使这组患者的锁骨上淋巴结复发率明显降低（5．3％和42．4％,P＝0．000）,腋窝淋巴结转移数≥4个的患者,做和不做腋窝放射治疗的10年腋窝淋巴结复发率分别为0％和6．5％,差别无显著性意义（P＝0．142）。全组患者只有1例出现内乳淋巴结复发,10年内乳淋巴结复发率为0．2％,结论：腋窝和内乳淋巴结复发少见,对腋窝淋巴结转移数≥4个的患者,建议行胸壁和锁骨上淋巴结照射,放射治疗有降低胸壁复发率的趋势,并能显著降低锁骨上淋巴结复发率。     

Time-course of local recurrence following conservative surgery and radiotherapy for early stage breast cancer

The time-course of local failure following conservative surgery and radiotherapy (S+RT) for early breast cancer is not well established. We therefore examined the time-course and patterns of breast recurrence as a first site of treatment failure in a group of 607 AJCC clinical Stage I or II invasive breast carcinomas treated from 1968-81. Sixty-seven patients had a breast failure (11%), corresponding to 5- and 10-year actuarial rates of 10% and 16%. The hazard rate (i.e., the risk per unit time of a failure) for any breast failure increased over the first 2 years, was fairly constant at about 2.5%/year over the period from 2 to 6 years after treatment, and then decreased to about 1%/year at 8 years. The majority of failures were at or near the primary tumor site (33 true recurrences (TR) and 15 marginal misses (MM). In addition there were 12 failures at sites at least several cm from the boosted volume (E), 6 recurrences in the skin without a parenchymal mass (S), and 1 patient with an unclassifiable failure. Recurrences at or near the primary site (TR/MM) occurred earlier (median 38.5 mo, range 12-87 mo) than recurrences at distant sites in the breast (E) (median 64.5 mo, range 26-90). The hazard rate for TR/MM increased over the first 2-1/2 years to reach approximately 2%/year, remained at that level till about 5 years after treatment, and then decreased to about 0.5%/year at 8 years following RT. By contrast, the hazard rate for E increased slowly with time to approximately 1%/year at 5 years, with little change in the rate after that time. We conclude that the time-course of the development of local recurrence after S+RT is protracted. The majority of failures appear at or near the primary tumor site; these are seen mainly in the first 7 years following RT. Recurrences at distant sites in the breast have an even more protracted time-course. Such recurrences are rare in the first 4 years following RT. Our results emphasize the need to obtain long follow-up in these patients, both to detect these recurrences promptly and to properly evaluate the results of S+RT.     

Compliance with consensus recommendations for the treatment of early stage breast carcinoma in elderly women

BACKGROUND: The goal of this study was to assess variations with age in the management of breast carcinoma and to identify determinants of care received. METHODS: A stratified random sample was selected among women age > or = 50 newly diagnosed with lymph node negative breast carcinoma in Quebec in 1988, 1991, and 1993. Information was abstracted from medical charts. Predictors of definitive locoregional treatment (total mastectomy with lymph node dissection or breast-conserving surgery with both axillary lymph node dissection and radiation therapy) were identified by multiple logistic regression analysis. RESULTS: Overall, 1174 patients age > or = 50 years with breast carcinoma were included. Women age > or = 70 years were much less likely to receive definitive locoregional treatment compared with women ages 50-69 years (48.7% vs. 83.5%; P < 0.0001). Older women were less likely to undergo surgery with breast preservation (76.7% vs. 86.3%; P < 0.0001), radiation therapy (54.7% vs. 90.5%; P < 0.0001), dissection of the axillary lymph nodes (55.6% vs. 86.3%; P < 0.0001), or chemotherapy (1.2% vs. 13.9%; P < 0.0001), but not treatment with tamoxifen (66.4% vs. 64.7%; P = 0.41). Adjusting for comorbidity and other characteristics related to the disease, the hospital, and the attending physician, age remained a strong determinant of the probability of receiving definitive locoregional treatment (odds ratio [OR], 0.14; 95% confidence interval [95% CI], 0.12-0.18 for women age > or = 70 years vs. women ages 50-69 years). The same association was observed when women who did not undergo lymph node dissection but who received systemic adjuvant treatment were considered to have received definitive therapy (OR, 0.13; 95% CI, 0.10-0.17) for women age > or = 70 years vs. women ages 50-69 years). CONCLUSIONS: Less aggressive patterns of care are provided to elderly breast carcinoma patients, independent of comorbidity. This could explain, at least in part, the sustained breast carcinoma mortality in this population.     

Nodal ratios in node-positive breast cancer--long-term study to clarify discrepancy of role of supraclavicular and axillary regional radiotherapy

PURPOSE: To study the absolute number of involved nodes/the number of nodes examined or the nodal ratio (NR) in breast cancer. The primary study endpoint was to evaluate the role of supraclavicular and axillary radiotherapy (SART) according to the NR. METHODS AND MATERIALS: From the Saskatchewan provincial registry of 1981-1995, the charts of 5,996 consecutive patients were retrieved to collect detailed prognostic factors. Among these patients, 1,985 were node positive. Because the NRs are more reliable the greater the number of nodes examined, we analyzed 1,255 patients with > or =10 nodes examined. Of these 1,255 patients, 667, 389, and 199 were categorized into three NR groups--low (< or =25%), medium (>25% to < or =75%), and high (>75%) nodal involvement, respectively. RESULTS: The NR correlated significantly with the primary tumor size (< or =2 cm, >2 to < or =5 cm, and >5 cm; p = 2.2 x 10(-16)), clinical stage group (p = 5.5 x 10(-16)), pathologic stage group (p < 2.2 x 10(-16)), and the risk of any first recurrence (p = 5.0 x 10(-15)) using chi-square tests. For a low NR, the 10-year overall survival rate with and without SART was 57% and 58% (p = 0.18), and the cause-specific survival rate was 68% and 71% (p = 0.32), respectively. For a medium NR, the 10-year overall survival rate with and without SART was 48% and 34% (p = 0.007), and the cause-specific survival rate was 57% and 43% (p = 0.002), respectively. For a high NR, the 10-year overall survival rate with and without SART was 19% and 10% (p = 0.005), and the cause-specific survival rate was 26% and 14% (p = 0.005), respectively. CONCLUSION: This is the first study demonstrating that for patients with > or =10 nodes examined, SART significantly improved the survival for the median and high NR groups but not for the low NR group.     

Adjuvant radiotherapy in early stage ovarian carcinoma

In a series of 228 women diagnosed with malignant ovarian tumors during the years 1980-87 radiotherapy was added as postoperative adjuvant therapy. Twenty-three cases with epithelial borderline carcinomas and 18 cases with nonepithelial tumors were excluded from the analysis. The remaining 187 cases of invasive epithelial ovarian carcinoma in FIGO stage I-II was a complete, consecutive, and total geographic series. After primary staging surgery lower abdomino-pelvic or whole abdominal radiotherapy was administered. The dose to the upper part of the abdomen was 20 Gy (fraction dose 1.0 Gy) and to the lower part and the pelvis 40 Gy (fraction dose 1.7 Gy). The patients were followed up for at least 10 years. During the follow-up 75 tumors (40%) recurred and were then treated with cisplatin-containing chemotherapy. Abdomino-pelvic (18%) and abdomino-pelvic-distant metastases (11%) were most frequent. Mean time to recurrence was 26 months. The 5-year overall survival of the complete series was 57% and the cancer-specific survival 66%. FIGO stage and tumor grade were the only independent and significant prognostic factors in a Cox multivariate analysis. Only cases in FIGO stage IA and grade 1 could be classified as low-risk cases with 5-year survival of 87%. All other cases showed a significantly worse prognosis and should be classified as intermediate or high-risk cases. Early radiation reactions were frequent (80%) but of little clinical significance. In 21 cases (11%) late radiation reactions were recorded. In 8 cases (4%) the reactions were regarded as severe and required surgical intervention or disabled the patient significantly. The results compare well with others reported in the literature.     

Complete axillary lymph node dissection for stage I-II carcinoma of the breast

We reviewed the complete axillary dissection specimens of 136 patients with stage I-II breast cancer to clarify the distribution of axillary lymph node metastases in this disease. Our series included 71 patients undergoing axillary dissection as part of a modified radical mastectomy (MRM) and 65 patients undergoing axillary dissection in conjunction with conservative surgery of the breast and definitive postoperative breast radiotherapy (CAD). These two groups of patients were comparable according to age, menopausal status, tumor size, and clinical stage. In all patients the pectoralis minor muscle was excised and all axillary tissue removed. Each specimen contained a median of 23 lymph nodes. The axillary levels (I, II, III) were determined according to the relationship of axillary tissue to the pectoralis minor muscle (lateral, inferior, medial). Thirty-nine percent of the lymph nodes were contained in level I, 41% in level II, and 20% in level III. There were no significant differences noted in the number of lymph nodes or in the distribution of lymph nodes according to axillary level between dissections performed as part of the MRM or those done as a single procedure (CAD). Sixty-five patients (47.8%) had one or more positive lymph nodes in their axillary specimen. The clinical and pathologic stage was determined and compared for all patients. Among patients judged to have a clinically negative axilla, 37.6% had histologically positive lymph nodes (clinical false-negative rate). For patients with a clinically positive axilla, 11.1% had, histologically, no evidence of metastatic disease (clinical false-positive rate). When the distribution of lymph node metastases according to axillary level was studied, it was found that 29.2% of lymph node-positive patients (or 14.0% of all patients) had metastases only to level II and/or III of the axilla, with level I being negative (skip metastases). This incidence of skip metastases was greater among clinically node-negative than among clinically node-positive patients, but was not related to the size or location of the primary tumor in the breast. In addition, it was found that 20.0% of lymph node-positive patients (or 9.6% of all patients) were converted from three or fewer to four or more positive nodes by analysis of lymph nodes contained in levels II and III. This conversion from three or fewer to four or more positive nodes was due primarily to information contained in level II, with level III contributing to a smaller degree.(ABSTRACT TRUNCATED AT 400 WORDS)     

大分割放疗治疗保乳手术后早期乳腺癌的疗效及安全性

目的 探讨常规放疗与大分割放疗对行保乳手术早期乳腺癌患者的疗效及安全性.方法 保乳手术早期乳腺癌患者共120例,以随机区组法分为常规放疗组(60例)和大分割放疗组(60例),术后分别行常规放疗(总放射剂量50 Gy/25 f,瘤床加量10 Gy/5 f)与大分割放疗(总放射剂量42.4 Gy/16 f,瘤床加量10 Gy/4 f)治疗.比较两组患者生存率、复发转移率、美容效果优良率及不良反应发生率等.结果 两组患者1、2、3年生存率比较差异均无统计学意义(98.3％ vs 100.0％,93.3％vs96.7％,88.3％vs90.0％,均P＞0.05),3年局部复发率和远处转移率比较差异均无统计学意义(5.0％ vs 1.7％,10.0％ vs 6.7％,均P＞0.05),美容效果优良率比较差异无统计学意义(88.3％ vs 90.0％,P＞0.05),不良反应发生率比较差异无统计学意义(P＞0.05).结论 常规放疗与大分割放疗用于行保乳手术早期乳腺癌患者具有相似临床疗效及安全性,而大分割放疗方案具有放疗次数少、疗程短及经济性好等优势.     

早期乳腺癌保乳术后放射治疗新进展

早期乳腺癌保乳术后放射治疗可以显著降低局部复发率,但是传统模式的全乳腺放疗对于一部分低危人群而言并非必要,属于过度治疗,因此在保证局部控制率的前提下,寻求新的放疗模式,如缩小照射范围、缩短治疗时间以及避免不必要的放疗成为乳腺癌研究与治疗的新方向.     

前哨淋巴结活检术在早期乳腺癌保腋窝治疗中的应用

目的：探讨乳腺癌前哨淋巴结活检术（sentonel lymph node biopsy,SLNB）对SLN阴性者进行保腋窝的可行性。方法：联合应用专利蓝（patent blue-v）和^99mTc标记的硫胶体（^99mTc-Sulphur colloid,^99mTc-Sc）行乳腺癌前哨淋巴结活检术。对SLN阴性并同意保腋窝者免除腋窝淋巴结清扫（axillary lymph node dissection,ALND）,对SLN阳性或虽SLN阴性但不同意保腋窝者仍行ALND。结果：2002年3月～2006年3月入组临床分期T1～2N0M0乳腺癌患者135例,均行SLNB。SLN阳性44例,其中42例行ALND,2例镜下有微小转移灶者仅行SLNB术后加腋窝淋巴结区域放疗;SLN阴性91例（67.4%）,其中的39例仅行SLNB,52例仍行ALND。全组SLNB准确率97.8%（132/135）,假阴性率6.8%（3/44）。全组中位随访43个月（24～72个月）,SLNB保腋窝者术后并发症明显低于ALND者（P〈0.05）,区域淋巴结无复发,ALND者区域淋巴结亦无复发。结论：SLNB保腋窝近期疗效满意具有良好的微创效果。     

Sequelae of axillary lymph node dissection in older women with stage 1 and 2 breast carcinoma

BACKGROUND: There are few data on the long-term sequelae of axillary dissection among older breast carcinoma patients. We describe the impact of axillary dissection in a cohort of older women. METHODS: A longitudinal cohort of 571 patients with Stage 1 and 2 breast carcinoma, 67 years and older, diagnosed between 1995 and 1997 from 29 hospitals in five regions, and followed for 2 years. Data were collected from patients and medical charts. The primary outcome was posttreatment quality of life. Generalized estimation equation longitudinal modeling was used to evaluate the outcome, controlling for baseline function, comorbidity, age, clinical status, and other factors. RESULTS: Sixty percent of women reported arm problems at some time in the 2 years after surgery. The cumulative risk of having arm problems 2 years posttreatment was three times higher (95% confidence interval 1.94-4.67) for women who underwent axillary surgery compared with women without axillary surgery, controlling for covariates. The effects of having axillary dissection and arthritis were multiplicative 2 years postsurgery. Arm problems were, in turn, the primary determinate of lower physical and mental functioning (P = 0.0001 and 0.04, respectively), controlling for other factors. Undergoing axillary dissection did not lessen fears about recurrence. CONCLUSIONS: Arm problems after axillary dissection have a consistent negative impact on quality of life, suggesting that the risks may outweigh the potential benefits in this population.