Perez Carlos A
Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri 63108, USA.
Cancer J. 2003 Nov-Dec;9(6):442-53. doi: 10.1097/00130404-200311000-00003.
To assess the significance of patient age, race, tumor-related prognostic parameters, status of surgical excision margins, and irradiation boost on incidence of ipsilateral breast relapse, and to review current issues in the management of T1-T2 breast cancer patients with conservation therapy.
Records of 1037 patients with histologically confirmed stage T1 and 308 patients with T2 carcinoma of the breast treated with breast conservation therapy from January 1970 through December 1997 were prospectively registered and evaluated. The mean follow-up for surviving patients was 6.6 years (range, 4-30 years), with a minimum follow up of 4 years for all patients.
There were 78 ipsilateral breast relapses (IBRs); the actuarial 10-year incidence of IBR was 7% for T1 and 11% for T2 tumors. In patients 40 years of age or younger, four of 24 (17%) with extensive intraductal component developed an ipsilateral breast relapse, compared with six of 80 (8%) without extensive intraductal component, in contrast to eight of 159 (5%) and 33 of 776 (4%) in postmenopausal patients with or without extensive intraductal component, respectively. In patients with T2 tumors, two of eight (25%) women 40 years or younger with extensive intraductal component, and seven of 50 (14%) without extensive intraductal component developed ipsilateral breast relapse. The corresponding values for the patients older than 40 years were five of 48 (10%) and 13 of 202 (6%), respectively. The incidences of ipsilateral breast relapses, correlated with status of surgical margins after re-excision in T1 tumors, were one of 30 (3.3%) for positive, no relapses in 40 patients with close margins, 16 of 438 (3.6%) for negative, and 18 of 196 (9%) for undetermined margins. In the patients with T2 tumors, ipsilateral breast relapses occurred in two of 16 patients (12.5%) with positive margins, one of 16 (6%) with close, seven of 105 (6.6%)with negative, and four of 68 (5.9%) with undetermined margins (differences not statistically significant). In patients with T1 tumors, negative margins, the 10-year relapse rate was the same (8%) in 559 to whom a boost was administered and in 66 without a boost. In patients with positive margins, the relapse rate was 4% in 215 receiving a boost (18-20 Gy) and 33% (two of six) without a boost. In patients with T2 tumors and negative margins, the rate of ipsilateral breast relapses in 16 patients to whom no boost was given was 12%, as opposed to 10% in 143 patients who received a boost. However, with T2 tumors and close or positive margins, the IBR rate at 10 years was 12% in 81 given a boost, in contrast to 40% (2 of 5) without a boost. In T1 tumors, the breast failure rate was two of 53 (3.7%) in women < or = 40 years receiving chemotherapy and eight of 51 (15.6%) without chemotherapy. For T2 tumors, the corresponding values were seven of 39 (17%) and two of 19 (10.5%), respectively. In women 40 years or younger with T1 tumors receiving hormones or not, the ipsilateral breast relapse rate was two of 19 (10.5%) and eight of 85 (9.4%), respectively; in the older than 40 years group, the corresponding values were six of 377 (1.6%) and 35 of 558 (6.2%). In the patients with T2 tumors, ipsilateral breast relapse rates were not statistically different in the various groups. On multivariate analysis, only age and adjuvant therapy were significant factors predictive of ipsilateral breast relapse.
Surgical excision margins status following adequate doses of radiation therapy was not a predictor of ipsilateral breast relapse. In patients younger than 40 years of age with extensive intraductal component, a somewhat higher breast relapse rate was noted but not enough to preclude breast conservation therapy. A boost of irradiation did not have a significant impact in the incidence of ipsilateral breast relapse in patients with negative margins, but it was of benefit to those with close or positive margins. Close attention to surgical margin status and delivery of higher doses of irradiation to the tumor excision site in patients with close or positive surgical margins will decrease the probability of breast relapses.
评估患者年龄、种族、肿瘤相关预后参数、手术切缘状态以及放疗加量对同侧乳腺复发发生率的影响，并回顾保乳治疗T1 - T2期乳腺癌患者管理中的当前问题。
前瞻性登记并评估了1970年1月至1997年12月期间接受保乳治疗的1037例组织学确诊为T1期乳腺癌患者和308例T2期乳腺癌患者的记录。存活患者的平均随访时间为6.6年（范围4 - 30年），所有患者的最短随访时间为4年。
共有78例同侧乳腺复发（IBRs）；T1肿瘤的10年IBR精算发生率为7%，T2肿瘤为11%。在40岁及以下的患者中，24例有广泛导管内成分的患者中有4例（17%）发生同侧乳腺复发，而80例无广泛导管内成分的患者中有6例（8%）复发，相比之下，绝经后有或无广泛导管内成分的患者中，分别为159例中的8例（5%）和776例中的33例（4%）。在T2肿瘤患者中，40岁及以下有广泛导管内成分的8例女性中有2例（25%）、无广泛导管内成分的50例中有7例（14%）发生同侧乳腺复发。40岁以上患者的相应数值分别为48例中的5例（10%）和202例中的13例（6%）。T1肿瘤再次切除后同侧乳腺复发率与手术切缘状态相关，切缘阳性的30例中有1例（3.3%）复发，40例切缘接近的患者无复发，切缘阴性的438例中有16例（3.6%）复发，切缘不确定的196例中有18例（9%）复发。在T2肿瘤患者中，切缘阳性的16例中有2例（12.5%）发生同侧乳腺复发，切缘接近的16例中有1例（6%），切缘阴性的105例中有7例（6.6%），切缘不确定的68例中有4例（5.9%）（差异无统计学意义）。在T1肿瘤患者中，切缘阴性的患者中，接受加量放疗的559例和未接受加量放疗的66例10年复发率相同（8%）。切缘阳性的患者中，接受加量放疗（18 - 20 Gy）的215例复发率为4%，未接受加量放疗的6例中有2例（33%）复发。在T2肿瘤且切缘阴性的患者中，未接受加量放疗的16例同侧乳腺复发率为12%，接受加量放疗的143例为10%。然而，对于T2肿瘤且切缘接近或阳性的患者，接受加量放疗的81例10年IBR率为12%，未接受加量放疗的5例中有2例（40%）复发。在T1肿瘤中，年龄≤40岁接受化疗的女性乳腺失败率为53例中的2例（3.7%），未接受化疗的为51例中的8例（15.6%）。对于T2肿瘤，相应数值分别为39例中的7例（17%）和19例中的2例（10.5%）。40岁及以下接受或未接受激素治疗的T1肿瘤女性中，同侧乳腺复发率分别为19例中的2例（10.5%）和85例中的8例（9.4%）；在40岁以上组中，相应数值分别为377例中的6例（1.6%）和558例中的35例（6.2%）。在T2肿瘤患者中，各亚组同侧乳腺复发率无统计学差异。多因素分析显示，只有年龄和辅助治疗是同侧乳腺复发的显著预测因素。
给予足够剂量放疗后，手术切缘状态不是同侧乳腺复发的预测因素。在40岁以下有广泛导管内成分的患者中，乳腺复发率略高，但不足以排除保乳治疗。加量放疗对切缘阴性患者同侧乳腺复发发生率无显著影响，但对切缘接近或阳性患者有益。密切关注手术切缘状态，并对切缘接近或阳性的患者在肿瘤切除部位给予更高剂量放疗，将降低乳腺复发的可能性。
