Lin Chun-Hung, Yang Hsuan-Ju, Hung Shih-Kai, Lee Moon-Sing, Chiou Wen-Yen, Chew Chia-Hui, Chen Liang-Cheng, Yu Ben-Hui, Hsu Feng-Chun, Lin Hon-Yi
Department of General Surgery, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan.
Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan.
Surgery. 2025 Jul 15;185:109539. doi: 10.1016/j.surg.2025.109539.
Limited data are available for comparing irradiated clinical outcomes between modified radical mastectomy and breast-conserving surgery for patients with pathologic stage III breast cancer, especially when stratified by molecular subtypes.
The present population-based cohort study used the Taiwan National Health Insurance Research Database. Patients with pathologic stage III breast cancer who underwent breast-conserving surgery plus radiotherapy or modified radical mastectomy plus radiotherapy from 2006 to 2019 were included in data analysis. The baseline characteristics of the breast-conserving surgery plus radiotherapy and modified radical mastectomy plus radiotherapy groups were matched using propensity scores, with exact matching for the molecular subtypes of breast cancer between the 2 groups. Local-regional recurrence, distant metastasis, disease-free survival, and overall survival as the primary outcomes were assessed using Fine and Gray's competing-risk regression model, stratified by breast cancer subtypes.
A total of 5,166 patients who underwent breast-conserving surgery plus radiotherapy (n = 2,583) and modified radical mastectomy plus radiotherapy (n = 2,583) were included. Overall, our results showed a lower incidence of local-regional recurrence with modified radical mastectomy plus radiotherapy than with breast-conserving surgery plus radiotherapy (0.6% vs 1.9%, P = .001; adjusted hazard ratio, 0.33; P = .0002). However, no difference was observed in the rates of distant metastasis, disease-free survival, and overall survival between the breast-conserving surgery plus radiotherapy and modified radical mastectomy plus radiotherapy groups. Notably, among those with luminal breast cancer, the risk of local-regional recurrence was lower in patients who underwent modified radical mastectomy plus radiotherapy than those who underwent breast-conserving surgery plus radiotherapy, with an adjusted hazard ratio of 0.28 (P = .022). For patients with human epidermal growth factor receptor 2-positive breast cancer, a lower risk of local-regional recurrence was observed in modified radical mastectomy + radiotherapy compared with breast-conserving surgery plus radiotherapy, with an adjusted hazard ratio of 0.06 (P = .0018). However, for triple-negative breast cancer, no differences were observed between the 2 groups in terms of local-regional recurrence, distant metastasis, disease-free survival, and overall survival.
Our findings indicated that modified radical mastectomy + radiotherapy offers a greater advantage in reducing the risk of local-regional recurrence compared with breast-conserving surgery plus radiotherapy in patients with pathologic stage III breast cancer, particularly those with luminal or human epidermal growth factor receptor 2-positive molecular subtypes. However, this advantage is not observed in other clinical outcomes, such as, distant metastasis, disease-free survival, and overall survival, and it does not have a significant effect in patients with triple-negative breast cancer. Further randomized controlled trials are necessary to establish robust clinical evidence.
关于病理分期为III期乳腺癌患者，改良根治性乳房切除术与保乳手术的放疗临床结局比较的数据有限，尤其是按分子亚型分层时。
本基于人群的队列研究使用了台湾全民健康保险研究数据库。对2006年至2019年期间接受保乳手术加放疗或改良根治性乳房切除术加放疗的病理分期为III期乳腺癌患者进行数据分析。使用倾向评分匹配保乳手术加放疗组和改良根治性乳房切除术加放疗组的基线特征，两组间乳腺癌分子亚型进行精确匹配。使用Fine和Gray竞争风险回归模型评估局部区域复发、远处转移、无病生存期和总生存期作为主要结局，并按乳腺癌亚型分层。
共纳入5166例接受保乳手术加放疗（n = 2583）和改良根治性乳房切除术加放疗（n = 2583）的患者。总体而言，我们的结果显示改良根治性乳房切除术加放疗的局部区域复发发生率低于保乳手术加放疗（0.6%对1.9%，P = 0.001；调整后风险比，0.33；P = 0.0002）。然而，保乳手术加放疗组和改良根治性乳房切除术加放疗组在远处转移率、无病生存期和总生存期方面未观察到差异。值得注意的是，在管腔型乳腺癌患者中，接受改良根治性乳房切除术加放疗的患者局部区域复发风险低于接受保乳手术加放疗的患者，调整后风险比为0.28（P = 0.022）。对于人表皮生长因子受体2阳性乳腺癌患者，改良根治性乳房切除术加放疗与保乳手术加放疗相比，局部区域复发风险更低，调整后风险比为0.06（P = 0.0018）。然而，对于三阴性乳腺癌，两组在局部区域复发、远处转移、无病生存期和总生存期方面未观察到差异。
我们的研究结果表明，对于病理分期为III期乳腺癌患者，尤其是管腔型或人表皮生长因子受体2阳性分子亚型患者，改良根治性乳房切除术加放疗在降低局部区域复发风险方面比保乳手术加放疗具有更大优势。然而，在其他临床结局如远处转移、无病生存期和总生存期方面未观察到这种优势，且对三阴性乳腺癌患者没有显著影响。需要进一步的随机对照试验来建立有力的临床证据。
