乳腺癌改良根治术后T1-2N1期患者局部区域复发的部位分析

目的 分析乳腺癌改良根治术后T1-2N1患者的局部区域复发(LRR)部位分布,探讨放疗的照射范围。方法 1997年9月至2015年4月中国医学科学院肿瘤医院收治2472例改良根治术后T1-2N1女性乳腺癌患者,均未行新辅助治疗。1898例未行术后放疗的患者纳入本研究,分析患者的局部和区域复发部位。采用Kaplan-Meier法进行局部复发率和区域复发率计算,采用Log-Rank法对影响患者局部复发和区域复发的各因素分别进行单因素分析,纳入单因素分析P值小于0.05的因素进行Cox回归法多因素分析。结果 中位随访时间71.3个月,164例(8.6%)患者发生局部和(或)区域复发。其中复发在锁骨上106例(65%),胸壁69例(42%),腋窝39例(24%),内乳19例(12%)。多因素分析显示年龄(>45岁/≤45岁)、肿瘤位置(其他象限/内象限)、T分期(T1/T2)、腋窝阳性淋巴结数(1个/2~3个)、激素受体(阳性/阴性)是局部复发和区域复发共同的影响因素。结论 乳腺癌改良根治术后T1-2N1期患者的LRR部位主要是锁骨上,其次是胸壁,腋窝和内乳少见。影响局部和区域复发的高危因素基本相似,放疗患者建议照射锁骨上区和胸壁。     

改良根治术后pT1-2N1期乳腺癌的局部区域复发部位——12个中心 5442例患者的联合分析

目的 分析改良根治术后pT1-2N1期乳腺癌患者的局部区域复发(LRR)部位及放疗对复发的影响。方法 收集中国12家医院符合条件的 5442例乳腺癌患者资料,分析放疗和未放疗患者的LRR部位及不同部位放疗对复发的影响。采用Kaplan-Meier法计算LRR率并log-rank法检验。结果 全组中位随访63.8个月,395例患者出现LRR。无论辅助放疗与否和不同分子分型,胸壁和锁骨上区均为最常见的LRR部位。全组胸壁照射和未照射患者的 5年胸壁复发率分别为2.5%和3.8%(P=0.003);锁骨上区照射和未照射患者的 5年锁骨上淋巴结复发率分别为1.3%和4.1%(P<0.001);腋窝照射和未照射患者的 5年无腋窝复发率分别为0.8%和1.5%(HR=0.31,95%CI为 0.04~2.23,P=0.219);内乳照射和未照射患者的 5年无内乳复发率分别为0.8%和1.5%(HR=0.45,95%CI为 0.11~1.90,P=0.268)。结论 改良根治术后pT1-2N1期乳腺癌患者的主要LRR部位是胸壁和锁骨上区,不受辅助放疗与否和分子分型的影响。胸壁和锁骨上区放疗显著降低相应部位的复发风险,而腋窝和内乳放疗未降低相应部位的复发风险。     

乳腺癌改良根治术后复发高危患者的放疗结果和预后因素分析

目的 总结本院高危乳腺癌患者改良根治术后的治疗结果,探讨放疗的作用和照射野的选择,并对生存预后因素进行分析.方法 回顾性分析381例T_3～T_4期和(或)腋窝淋巴结转移数≥4个的改良根治术后乳腺癌患者临床资料.用Kaplan-Meier法计算生存率,并Logrank法检验.单因素分析临床病理和治疗因素对生存率的影响,多因素分析用Cox回归模型.结果 中位随访时间为48个月.总5年无局部区域复发率为89.7%、总生存率为76.8%.放疗显著提高5年无局部区域复发生存率(93.4%:77.1%,χ~2=19.95,P=0.000)和总生存率(80.9%:62.3%,χ~2=15.47,P=0.001).胸壁和锁骨上区域照射能提高患者的5年无胸壁复发生存率(96.8%:86.2%;χ~2=12.66,P=0.001)和无锁骨上淋巴结复发生存率(97.7%:90.7%,χ~2=9.98,P=0.002),腋窝照射对5年无腋窝复发生存率无影响(98.4%:96.1%,χ~2=0.74,P=0.389).多因素分析显示未放疗(χ~2=14.42,P=0.000)、腋窝淋巴结阳性数≥10个(χ~2=21.60,P=0.000)和T_4期(χ~2=10.79,P=0.001)是总生存率的独立不良预后因素.结论 T_3～T_4期和(或)腋窝淋巴结转移数≥4个乳腺癌患者改良根治术后放疗显著降低局部复发率和提高总生存率,照射部位可选择同侧胸壁和锁骨上淋巴结引流区.     

T4期乳腺癌患者改良根治术后胸壁放疗加量的疗效及预后分析

目的分析T4期乳腺癌患者改良根治术后胸壁放疗加量的疗效。方法回顾分析2000-2016年收治的148例T4期、改良根治术后放疗的乳腺癌患者资料,胸壁放疗加量组57例,不加量组91例。放疗采用常规+胸壁电子线、三维适形+胸壁电子线、调强放疗+胸壁电子线照射,加量组EQD2>50Gy。全组患者均接受新辅助化疗。Kaplan-Meier法生存分析并Logrank检验差异,Cox模型多因素预后分析。结果中位随访时间67.2个月,5年胸壁复发(CWR)、局部区域复发(LRR)、无瘤生存(DFS)、总生存(OS)率分别为9.9%、16.2%、58.0%、71.4%。胸壁放疗加量和不加量的5年CWR、LRR、DFS、OS率分别为14%和7%、18%和15%、57%和58%、82%和65%(P>0.05)。多因素分析显示胸壁加量与否对预后无显著影响(P>0.05)。45例复发高危组患者中放疗加量组似乎有较高的OS率(P=0.058)、DFS率(P=0.084)和较低的LRR率(P=0.059)。结论T4期乳腺癌患者异质性较强,胸壁放疗加量对全组患者无明显获益。对于有脉管瘤栓阳性、pN2-N3、激素受体阴性中2~3个高危因素患者胸壁放疗加量有改善疗效趋势。     

T1～T2期伴1～3个腋窝淋巴结转移乳腺癌患者改良根治术后放疗的作用

目的 回顾性分析370例T1～T2期、腋窝淋巴结转移数为1～3个乳腺癌患者改良根治术后的治疗结果,探讨放疗的作用.方法 用Kaplan-Meier法计算生存率,分析放疗对生存率和复发率的影响,同时分析对未放疗患者复发率有影响的临床病理因素.结果 中位随访时间为50个月(9～91个月).全组患者的5年无局部区域复发率为91.0%,总生存率为85.4%.放疗显著提高5年无局部区域复发生存率(100%和89.5%;x2=5.17,P=0.023),对总生存率无影响.对319例未行放疗患者的单因素分析显示T分期、腋窝淋巴结阳性数、C-erbB-2和PR状态是预测无复发生存率的有意义因素.结论 T1～T2期且腋窝淋巴结转移数1～3个乳腺癌患者改良根治术后,放疗显著降低局部复发率,但对总生存率无影响.T分期、腋窝淋巴结阳性数、C-erbB-2和PR状态是预测元复发生存率的有意义因素.     

1999-2008年中国乳腺癌根治术后放疗部位变化的临床流行病学研究

目的 了解中国乳腺癌根治术后放疗部位变化。方法 随机纳入国内7家医院1999-2008年间乳腺癌根治术后放疗并有详细放疗部位资料的乳腺癌患者资料,分析放疗部位随治疗年代变化情况及不同医院间差别,以及放疗部位与临床病理因素的关系。采用SAS统计软件行Cochran-Armitage 趋势检验和χ²检验。结果 661例患者中90.2%(596例)、91.5%(606例)、29.6%(196例)和44.9%(297例)患者接受了胸壁、锁骨上下、腋窝和内乳放疗。1999-2008年间胸壁放疗的使用显著增加(P=0.000),腋窝、内乳区的放疗使用显著下降(P=0.027、0.000)。胸壁、腋窝、内乳放疗以及锁骨上下区放疗的使用不同医院间不同(P=0.008、0.000、0.000、0000)。腋窝放疗与腋窝淋巴结状态有关,内乳放疗与原发肿瘤部位有关。结论 国内乳腺癌根治术后放疗照射部位在不同年代和不同医院间有很大差别。多数患者接受了胸壁和锁骨上下区放疗,腋窝和内乳的放疗显著下降。     

Ⅰ期、Ⅱ期乳腺癌术后局部复发的放疗及预后

目的：探讨乳腺癌术后局部区域复发的规律和再放疗的预后。方法：回顾分析45例Ⅰ期、Ⅱ期乳腺癌术后局部区域复发的情况以及复发后放疗的预后。26例采用局部野放疗，19例采用扩大野放疗。结果：T2及腋窝淋巴结转移数≥4枚或≥20％的病例占复发病例的73％。复发的部位依次为锁骨上、多部位、胸壁、腋窝、内乳。复发后2a生存率40％、无瘤生存率24．4％，2次局部区域复发率31％，术后2a以上复发的2a生存率64％，2a以下29％。首次复发累及多部位生存率18．2％，较单一锁骨上(47．4％)及胸壁(30％)低，累及锁骨上局部复发率高于胸壁，远处转移率低于胸壁，2次局部复发胸壁最高达57％，照射野采用广泛野的局部复发率低于采用局部野。结论：对Ⅰ期、Ⅱ期乳腺癌中腋窝淋巴结阳性≥4枚或≥20％的病例应常规行术后放疗，对术后局部区域复发的病例应采用包括胸壁及锁骨上下大范围照射。     

78例乳腺癌改良根治术后pT3N0M0期患者放疗价值探讨

目的 探讨乳腺癌改良根治术后病理分期为T₃N₀期患者的术后放疗价值。方法 回顾分析1997-2014年收治的乳腺癌改良根治术后患者资料,筛选标准为女性、术后病理提示浸润性癌、肿瘤最大径>5 cm且腋窝淋巴结未见转移、未接受新辅助化疗及内分泌治疗,且无远处转移及其他第二原发癌。78例符合条件。40例(51%)接受术后放疗,67例(86%)接受辅助化疗。Kaplan-Meier法计算DFS、OS及LRR率,组间差异用Logrank法检验。结果 中位随访时间79个月(6~232个月),5年OS、DFS和LRR分别为89%、87%和2%。放疗组与未放疗组患者5年DFS分别为84%与91%(P=0.641),5年OS分别为84%与96%(P=0.126),5年LRR分别为0%和5%。仅ER/PR状态、分子分型影响患者DFS (P=0.002、0.031)。未放疗组有1例患者出现胸壁复发。结论 乳腺癌改良根治术后T₃N₀M₀期患者LRR率较低,仅ER/PR状态及分子分型影响患者DFS。在有效系统全身治疗基础上术后病理T₃N₀患者可能不需全部接受胸壁+锁骨上野放疗,但仍需大样本病例证实。     

术后放疗在T1～T2期腋窝淋巴结1～3个转移乳腺癌中的临床应用

目的探讨T1～T2期腋窝淋巴结1～3个转移乳腺癌改良根治术后放疗的疗效及影响术后复发的相关因素。方法回顾分析496例腋窝淋巴结1～3个转移的早期患者,所有患者均行乳腺癌改良根治术,术后行放射治疗者210例,未行放疗者286例。术后随访满5年,组间差异采用χ2检验,影响复发率的多因素分析采用Logistic回归分析。结果全组5年生存率：92.3%（458/496）,5年局部复发率7.3%（36/496）,远处转移率12.1%（60/496）。术后放疗组与未放疗组的局部复发率分别为4.3%和9.4%（χ2=4.780,P=0.029）。Logistic回归分析提示,术后复发与是否行肿瘤局切术[Exp（B）=3.420,P=0.004]、月经状况[Exp（B）=0.336,P=0.032]、肿块位置[Exp（B）=4.744,P=0.000]、淋巴结清扫个数[Exp（B）=5.507,P=0.000]相关。结论术后放疗可降低T1～T2期腋窝淋巴结1～3个转移乳腺癌患者的局部复发率;肿瘤局切术后、绝经前、肿块位于中央区或内象限、淋巴结清扫数〈10个等为影响肿瘤复发的独立高危因素,对这部分患者应积极考虑行术后放疗。     

早期乳腺癌原发象限对根治术后1~3个腋窝淋巴结转移患者预后预测价值探讨

目的 探讨早期乳腺癌原发象限对根治术后1~3个腋窝淋巴结转移患者LRR的预测价值。方法 回顾分析1998—2010年在本院手术的656例病理诊断为pT_1-2N₁M₀期且均未术后放疗患者资料。原发肿瘤位于内象限156例、中央区45例、外象限455例。观察终值为LRR和LRFS。Kaplan Meier法计算LRR、LRFS并Logrank检验和单因素预后分析, Cox模型多因素预后分析。结果 5、10年样本数分别为416、191例,5、10年LRR分别为8.6%、12.9%,LRFS分别为86.2%、76.4%。单因素分析显示年龄、pT分期、Ki67水平、分子分型和肿瘤位置是影响LRR因素(P=0.000、0.006、0.017、0.004、0.000)。多因素分析显示年龄、肿瘤位置和分子分型也是LRFS的预后影响因素(P=0.0012、0.012、0.005),且随危险因素增加(危险因素≥2个),原发内象限患者LRR迅速升高,LRFS降低,原发外象限、中央区者则无变化。结论 肿瘤原发象限对早期乳腺癌根治术后pT_1-2N₁M₀期患者LRR和LRFS有预测价值。肿瘤位于内象限者LRR高、LRFS低,对高危组患者复发风险的预测价值更大。     

Low risk of locoregional recurrence of primary breast carcinoma after treatment with a modification of the Halsted radical mastectomy and selective use of radiotherapy

BACKGROUND: The purpose of the current study was to evaluate the locoregional recurrence rate after treatment of patients with operable breast carcinoma with a modification of the Halsted radical mastectomy and the selective use of radiotherapy and to identify risk factors for locoregional recurrence. METHODS: Between 1979-1987, 691 consecutive patients underwent mastectomy after a negative biopsy of the axillary apical lymph nodes. The median age of the patients was 59 years (range, 26-89 years). The clinical tumor size was < 2 cm in 72 patients, 2-5 cm in 387 patients, and >5 cm in 169 patients; 16 patients had a T4 tumor. Surgery was comprised of a modification of the Halsted radical mastectomy, including at least part of the pectoralis major muscle and the entire pectoralis minor muscle, in 573 patients; 303 patients had positive axillary lymph nodes. Adjuvant radiotherapy to the chest wall and regional lymph nodes was given to 74 patients, whereas an additional 414 patients underwent irradiation to the internal mammary and medial supraclavicular lymph nodes. The median follow-up was 91 months. RESULTS: The actuarial overall survival rate was 82% at 5 years and 63% at 10 years. The 10-year chest wall and regional lymph node control rates, including patients with prior distant failures, were 95% and 94%, respectively. The only two significant prognostic factors for locoregional recurrence on multivariate analysis were lymph node status and pathologic tumor size. CONCLUSIONS: Excellent locoregional control can be achieved with a modified technique of radical mastectomy in patients with negative apical biopsy and the selective use of comprehensive radiotherapy. These results may serve as a reference outcome for comparison with other locoregional treatment strategies.     

The role of postoperative radiotherapy in node negative breast cancer patients with pT3-T4 disease.

AIMS: To evaluate the role of postmastectomy radiotherapy (PMRT) in patients with pT3-T4N0M0 breast cancer. METHODS: 156 patients with T3-T4N0M0 breast cancer were retrospectively analyzed. RESULTS: Locoregional recurrences were seen in 17 of 156 patients with a median time for development of 27 months (5.7-248.7 months). Two of 9 patients who were not treated with post-operative radiation therapy had locoregional recurrence as compared with 16 of 147 patients receiving radiotherapy. In multivariate analysis, presence of locoregional recurrence was the only significant prognostic factor for overall survival (18% vs. 86%, p<0.001, RR=9.05). The patients with a median number of dissected lymph nodes >or=10 had a significantly better locoregional disease free survival rate as compared with patients with dissected lymph nodes <10 (90% vs. 78%, p=0.04). Chest wall recurrences were clearly higher in patients without chest wall RT since 5 of 49 patients without RT had recurrences in the chest wall region while only 4 of 107 who received chest wall RT had recurrence. However receiving RT to peripherical lymphatic regions had no additional effect on reducing recurrences in these regions (5% vs. 4%). CONCLUSIONS: Due to the lack of phase III randomized trials directly addressing the role of postmastectomy radiotherapy in these stages, our series suggest that postmastectomy radiotherapy to the ipsilateral chest wall is recommended for patients with PT3N0 and T4N0 breast cancer. The need for irradiating axillary or supraclavicular region shall be neglected in patients who undergo sufficient axillary sampling.     

Radiotherapy following mastectomy: indication and contraindication of chest wall irradiation

Purpose: To determine in which cases radiotherapy of the chest wall following mastectomy is indicated, based on the local recurrent rate in patients with locally advanced breast cancer.

Methods and Materials: From 1984 until 1994, 105 patients who had four or more histopathologically confirmed axillary nodes metastases, or T3-4Nany, were subjected to mastectomy and were administered radiotherapy postoperatively using the hockey-stick field, which included the ipsilateral supraclavicular fossa and internal mammary nodes, except the chest wall. Median age was 51 years old (range, 23 to 82 years old). Eighty-five patients underwent radical mastectomy, 18 modified radical mastectomy, and 2 extended radical mastectomy. Fraction size was 2 Gy/day, the weekly fraction size was 10 Gy and the total dose ranged from 44 Gy to 54 Gy (median 50 Gy). Seventy-four patients were administered adjuvant chemotherapy, and 61 patients were administered hormone therapy.

Results: The 5-year disease-free survival rates of the whole study population were 66%. The 5-year chest wall recurrence rates were 10%. The 5-year chest wall recurrence rates of the patients who had no vascular invasion (n = 19) and the patients who had definite vascular invasion (n = 38) were 0% and 24%, respectively (p = 0.036). All the patients who presented chest wall recurrence had four or more axillary nodes metastases. Nine of the 10 patients who presented chest wall recurrence had definite vascular invasion, while there was no information about vascular invasion for the remaining patient. Factors such as age, pathological subtypes, tumor location, estrogen receptors, extent of resection, chemotherapy, and hormone therapy did not influence the development of chest wall recurrence.

Conclusion: Among patients with breast cancer who have four or more positive axillary nodes or T3-4Nany, those who have no vascular invasion or less than 4 axillary nodes metastases do not need to be subjected to chest wall irradiation after radical mastectomy.     

Radiation therapy in operable breast cancer: results from the Stockholm trial on adjuvant radiotherapy

In a randomized trial, 960 women with Stage 1-3 operable breast cancer were treated by a modified radical mastectomy alone, or by the same procedure, preceded or followed by radiotherapy (4500 rad to the breast/chest wall, and internal mammary, axillary and supraclavicular lymph nodes). Up to ten years after treatment, there is an increasing gap between the recurrence-free survival of the irradiated patients and the surgical controls. Between the two types of radiotherapy, there was no difference. There were significantly fewer distant metastases and a tendency for improved survival in node positive patients treated with postoperative radiotherapy, compared to the surgical controls, this difference was, however, statistically not significant.     

术后放疗在伴有腋窝淋巴结1～3 枚阳性T2 期乳腺癌中的作用

目的:探讨腋窝淋巴结1~3 枚阳性的T2 期乳腺癌根治术后是否需要接受放疗及放疗靶区的选择。方法:回顾性分析天津医科大学附属肿瘤医院1997年6 月~1998年12月根治术后经病理证实腋窝淋巴结1~3 枚阳性的T2 期乳腺癌患者103 例,其中44例未接受放疗,59例接受内乳区和锁骨上淋巴引流区放疗。所有患者术前腋窝均未触及肿大淋巴结,均未发现远处转移。分析患者的生存率、无瘤生存率、局部复发率及远处转移率。定量资料采用t 检验,计数资料比较采用χ2检验,生存率计算采用Kaplan-Meier 法,并用Log-rank 检验。结果:未放疗组和放疗组的10年生存率分别为56.8% 、72.9%（χ2=2.805,P=0.094）,10年局部复发率分别为27.3% 、10.2%（χ2=5.112,P=0.035）,远处转移率分别为43.2% 、22.0%（χ2=5.263,P=0.031）,10年无瘤生存率分别为50.0% 、64.4%（χ2=4.063,P=0.044）。 两组患者胸壁复发率为7.8% 。两组患者均未出现内乳淋巴引流区复发。内乳区放疗未能提高患者的生存率、降低局部复发率及远处转移率。结论:T2 期乳腺癌根治术后腋窝淋巴结1~3 枚阳性患者术后放疗降低了患者的局部复发率、远处转移率,提高了患者的生存率及无瘤生存率。内乳淋巴引流区复发少见,建议不给予内乳区放疗。建议T2 期腋窝淋巴结1~3 枚阳性乳腺癌患者根治术后给予胸壁及锁骨上区放疗。      

术后放疗对T1-2N1M0期三阴乳腺癌患者预后的影响

目的 分析T1-2N1M0期三阴性乳腺癌（TNBC）患者行改良根治术后放疗与否对生存的影响。方法 回顾性分析2004年1月至2010年9月接受改良根治术后129例T1-2N1M0期TNBC患者的临床资料,其中61例行术后常规放疗（放疗组）,68例未行放疗（未放疗组）。分析两组5年总生存率、5年无局部复发生存率和5年无病生存率以及影响局部复发的因素。结果 中位随访时间为67个月,全组患者中27例（20.9％）出现局部区域复发。放疗组较未放疗组提高了5年无局部复发生存率（88.5％ vs. 70.6％,P=0.017）和5年无病生存率（78.7％ vs.63.2％, P=0.068）。放疗组和未放疗组的5年生存率分别为88.5％和82.4％（P=0.341）。单因素分析显示年龄、T分期、淋巴结阳性数、是否放疗是影响无局部复发生存的预后因素（P＜0.05）。多因素分析显示未放疗（HR=3.432,P=0.010）和淋巴结3枚阳性（HR=2.915,P=0.020）是影响局部区域复发的独立预后因素。结论 术后放疗可明显改善T1-2N1M0期TNBC患者的无局部复发生存。淋巴结3枚阳性者局部控制更差,增加区域淋巴结照射是可行的。