局部区域淋巴结照射对新辅助化疗治疗阳性淋巴结乳腺癌患者的长期影响。
Long-Term Impact of Regional Nodal Irradiation in Patients With Node-Positive Breast Cancer Treated With Neoadjuvant Systemic Therapy.
机构信息
Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas.
出版信息
Int J Radiat Oncol Biol Phys. 2018 Nov 1;102(3):568-577. doi: 10.1016/j.ijrobp.2018.06.016. Epub 2018 Jun 19.
PURPOSE
The impact of regional nodal irradiation (RNI) on locoregional recurrence (LRR) and any disease recurrence (DR) in women with node-positive breast cancer who receive neoadjuvant systemic therapy (NAT) is unknown.
METHODS AND MATERIALS
The impact of RNI on LRR and DR was estimated with the cumulative incidence method in 1289 women with stage II to III breast cancer with cytologically confirmed axillary metastases who received NAT between 1989 and 2007. Multicovariate Cox regression analysis was performed to examine the effect of RNI after accounting for other predictive and prognostic variables.
RESULTS
The median follow-up after definitive surgery was 10.2 years. Axillary pathologic complete response (pCR) was observed in 368 of 1289 patients (28.5%). On univariate analysis, axillary pCR reduced 10-year LRR risk from 9.7% to 4.8% (P = .006) and DR risk from 43.0% to 17.0% (P < .001). RNI was administered to 1080 of 1289 patients (83.8%). On univariate analysis, RNI did not affect 10-year LRR risk (no RNI, 9.4%; RNI, 8.1%; P = .62) or DR risk (no RNI, 31.3%; RNI, 36.5%; P = .16). On multicovariate analysis, RNI significantly reduced the risk of LRR (hazard ratio, 0.497; 95% confidence interval [CI], 0.279-0.884; P = .02) and DR (hazard ratio, 0.731; 95% CI, 0.541-0.988; P = .04) and showed a particularly strong reduction in risk of DR in patients with HER2+ disease who received trastuzumab (hazard ratio, 0.237; 95% CI, 0.109-0.517; P = .0003). A nomogram to predict 10-year LRR risk with and without RNI has been generated to assist clinicians in individualizing treatment decisions based on patient and disease characteristics and response to NAT.
CONCLUSIONS
Adjuvant RNI reduces risk of LRR and DR in patients with breast cancer with axillary metastases who receive NAT across subtypes and particularly decreases the risk of DR in HER2+ breast cancer treated with trastuzumab. Enrollment on the National Surgical Adjuvant Breast and Bowel Project B-51/Radiation Therapy Oncology Group 1304 protocol is encouraged to help determine whether RNI can be omitted in patients with axillary pCR to NAT.
目的
对于接受新辅助全身治疗（NAT）后腋窝淋巴结阳性的乳腺癌患者，区域淋巴结照射（RNI）对局部区域复发（LRR）和任何疾病复发（DR）的影响尚不清楚。
方法与材料
我们采用累积发生率方法，评估了 1289 例接受了 1989 年至 2007 年期间接受的 NAT 的 II 期至 III 期乳腺癌伴细胞学证实的腋窝转移患者中 RNI 对 LRR 和 DR 的影响。多变量 Cox 回归分析用于检查在考虑其他预测和预后变量后 RNI 的效果。
结果
明确手术后的中位随访时间为 10.2 年。1289 例患者中有 368 例（28.5%）观察到腋窝病理完全缓解（pCR）。单因素分析显示，腋窝 pCR 使 10 年 LRR 风险从 9.7%降至 4.8%（P=0.006），DR 风险从 43.0%降至 17.0%（P<0.001）。1289 例患者中有 1080 例（83.8%）接受了 RNI。单因素分析显示，RNI 并未影响 10 年 LRR 风险（无 RNI，9.4%；RNI，8.1%；P=0.62）或 DR 风险（无 RNI，31.3%；RNI，36.5%；P=0.16）。多因素分析显示，RNI 显著降低了 LRR 风险（风险比，0.497；95%置信区间[CI]，0.279-0.884；P=0.02）和 DR 风险（风险比，0.731；95%CI，0.541-0.988；P=0.04），并显示在接受曲妥珠单抗治疗的 HER2+疾病患者中 DR 风险降低尤其明显（风险比，0.237；95%CI，0.109-0.517；P=0.0003）。已生成预测有无 RNI 的 10 年 LRR 风险的列线图，以帮助临床医生根据患者和疾病特征以及对 NAT 的反应来个体化治疗决策。
结论
在接受 NAT 的腋窝淋巴结转移的乳腺癌患者中，辅助 RNI 降低了 LRR 和 DR 的风险，并且在接受曲妥珠单抗治疗的 HER2+乳腺癌患者中尤其降低了 DR 的风险。鼓励入组国家外科辅助乳腺和肠道项目 B-51/放射治疗肿瘤学组 1304 方案，以帮助确定在接受 NAT 后腋窝 pCR 的患者中是否可以省略 RNI。
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