Veronesi U, Marubini E, Del Vecchio M, Manzari A, Andreola S, Greco M, Luini A, Merson M, Saccozzi R, Rilke F
Istituto Nazionale Tumori, Milan, Italy.
J Natl Cancer Inst. 1995 Jan 4;87(1):19-27. doi: 10.1093/jnci/87.1.19.
Local disease recurrences are a concern in conservative breast cancer surgery, and many studies have attempted to identify risk factors for these events. It is important to distinguish local recurrences linked to increased risk of distant spread from those due to inadequate local treatment.
We evaluated the incidence of local and distant recurrences according to demographic, biological, and pathologic variables in a large series of women who were conservatively and uniformly treated for breast cancer, with the aim of identifying women in whom local failure is predictive for distant metastases and who are therefore candidates for aggressive systemic treatment.
Medical records of 2233 women who had been hospitalized at the Milan Cancer Institute from 1970 to 1987 were analyzed. All women received quadrantectomy and axillary lymph node dissection followed by radiotherapy for the breast. Quadrantectomy is breast-conserving removal of most of the affected quadrant by a radial incision that includes part of the skin. The end points considered were local failures (including local recurrences and new ipsilateral carcinomas) and distant metastases. Statistical analysis employed the competing risks and multiple failures approaches.
There were 119 local recurrences, 32 new ipsilateral carcinomas, and 414 distant metastases as first events. The timing of local failures and distant metastases differed: The yearly probability for local failures was approximately 1% up to the 10th year and for distant metastases was 5% in the 2nd year and decreased progressively until the 8th year. Young age was an important risk factor, with peritumoral lymphatic invasion also predictive for local and distant recurrences. Tumor size and axillary lymph node involvement were not related to local recurrence but were important predictors of distant metastases. Extensive intraductal component was only a risk factor for local recurrence. Early (< 2 years) local failure predicted for distant metastases compared with later failure. In local failure patients, the 5-year survival rate was 69% from failure.
Local recurrences and distant metastases are partially independent events that occur at different times; several predicting factors also differ. However, women with local recurrences have increased risk of distant metastases. In particular, women 35 years old or younger at first diagnosis who had initial peritumoral lymphatic invasion and local recurrence within 2 years are at high risk for distant spread. For recurrence in cases with an extensive intraductal component or where initial local surgery was possibly inadequate, women are at lower risk.
局部疾病复发是保乳乳腺癌手术中令人担忧的问题，许多研究试图确定这些事件的风险因素。区分与远处转移风险增加相关的局部复发和因局部治疗不足导致的局部复发很重要。
我们根据人口统计学、生物学和病理学变量，评估了一大系列接受乳腺癌保守且统一治疗的女性的局部和远处复发发生率，目的是确定那些局部失败可预测远处转移的女性，因此她们是积极全身治疗的候选者。
分析了1970年至1987年在米兰癌症研究所住院的2233名女性的病历。所有女性均接受象限切除术和腋窝淋巴结清扫术，随后进行乳房放疗。象限切除术是通过包括部分皮肤的放射状切口对受影响象限的大部分进行保乳切除。所考虑的终点是局部失败（包括局部复发和同侧新发癌）和远处转移。统计分析采用竞争风险和多重失败方法。
首次事件中有119例局部复发、32例同侧新发癌和414例远处转移。局部失败和远处转移的时间不同：直到第10年局部失败的年概率约为1%，而远处转移在第2年为5%，并逐渐下降直至第8年。年轻是一个重要的风险因素，肿瘤周围淋巴浸润也可预测局部和远处复发。肿瘤大小和腋窝淋巴结受累与局部复发无关，但却是远处转移的重要预测因素。广泛的导管内成分仅是局部复发的风险因素。与后期失败相比，可以早期（<2年）局部失败预测远处转移。在局部失败患者中，自失败起5年生存率为69%。
局部复发和远处转移是在不同时间发生的部分独立事件；几个预测因素也不同。然而，发生局部复发的女性远处转移风险增加。特别是初次诊断时年龄在35岁及以下、最初有肿瘤周围淋巴浸润且在2年内发生局部复发的女性，远处转移风险很高。对于导管内成分广泛或最初局部手术可能不充分的病例中的复发，女性风险较低。
