Leborgne F, Leborgne J H, Ortega B, Doldan R, Zubizarreta E
Instituto de Radiología, Hospital Pereira Rossell, Montevideo, Uruguay.
Int J Radiat Oncol Biol Phys. 1995 Feb 15;31(4):765-75. doi: 10.1016/0360-3016(94)00414-5.
This study retrospectively assesses the patterns of failure in conservatively treated early stage breast cancer patients by correlating various clinical, pathologic, and treated-related factors with local, axillary, and distant relapse.
Between 1973 and 1990, 796 patients (817 breasts) received breast conservation surgery followed by radiotherapy. Local recurrences were counted as events even if they occurred simultaneously or after the appearance of axillary or distant metastases.
The 10-year actuarial relative disease-free survival (DFS) rate for T1N0, T2N0, and T1-2N1 was 82%, 71%, and 54%, respectively. Stage N0 patients had a significant DFS advantage over N1 patients (p = 0.02). The 15-year actuarial local recurrence-free rate for T1 and T2 tumors was 82% and 87%, respectively (p = nonsignificant). Univariate analysis identified three significant risk factors for local relapse: (a) 48 breasts with tumors showing an extensive intraductal component had a crude local recurrence rate of 23% compared to 8% for 769 breasts without intraductal component (p = 0.0016); (b) the actuarial 10-year local recurrence-free rate for patients under age 40 years was 64% compared to 88% for patients over 40 years (p < 0.0001); (c) the 10-year actuarial local recurrence-free rate for 416 postmenopausal women without adjuvant tamoxifen was 83% compared to 97% for 107 postmenopausal women with tamoxifen (p = 0.0479). Salvage therapy for operable local recurrent patients resulted in a 8-year actuarial DFS rate of 47%, significantly lower than that obtained with primary treatment. The incidence of axillary relapse as the first sign of recurrence was 2%, and could be correlated with the lack of axillary dissection (p < 0.0000005) and primary tumor size (p = 0.03). Radiotherapy to the axilla did not influence axillary relapse. Actuarial 5-year DFS rate after treatment of isolated axillary recurrence was 27%. Axillary failure was a marker for distant failure. Contralateral breast cancer occurred in 8% of patients and did not have a detrimental effect on survival. Adjuvant tamoxifen decreased the 9-year actuarial incidence of contralateral breast cancer from 10% to 4% (p = 0.053).
Tumors with extensive intraductal component, age under 40 years, and the omission of adjuvant tamoxifen in postmenopausal women increased local recurrence rate. Stage T2 and the lack of axillary dissection increased axillary recurrence rate. Stage N+ and local or axillary relapse increased distant failure rate. Axillary irradiation did not influence locoregional control nor survival. Improved therapy is needed for relapsing patients.
本研究通过将各种临床、病理及治疗相关因素与局部、腋窝和远处复发情况相关联，对早期乳腺癌保守治疗患者的失败模式进行回顾性评估。
1973年至1990年间，796例患者（817侧乳房）接受了保乳手术及术后放疗。即使局部复发与腋窝或远处转移同时出现或在其之后出现，也将其计为事件。
T1N0、T2N0和T1 - 2N1患者的10年精算无病生存率（DFS）分别为82%、71%和54%。N0期患者的DFS显著优于N1期患者（p = 0.02）。T1和T2肿瘤患者的15年精算局部无复发生存率分别为82%和87%（p = 无显著性差异）。单因素分析确定了三个局部复发的显著危险因素：（a）48侧乳房的肿瘤具有广泛的导管内成分，其局部复发粗率为23%，而769侧无导管内成分的乳房局部复发率为8%（p = 0.0016）；（b）40岁以下患者的10年精算局部无复发生存率为64%，40岁以上患者为88%（p < 0.0001）；（c）416例未接受辅助他莫昔芬治疗的绝经后女性的10年精算局部无复发生存率为83%，107例接受他莫昔芬治疗的绝经后女性为97%（p = 0.0479）。可手术的局部复发患者的挽救治疗导致8年精算DFS率为47%，显著低于初次治疗的DFS率。以腋窝复发作为复发的首个迹象的发生率为2%，且与未进行腋窝淋巴结清扫（p < 0.0000005）及原发肿瘤大小（p = 0.03）相关。腋窝放疗不影响腋窝复发。孤立腋窝复发治疗后的5年精算DFS率为27%。腋窝失败是远处失败的一个标志。对侧乳腺癌发生在8%的患者中，对生存无不利影响。辅助他莫昔芬将对侧乳腺癌的9年精算发生率从10%降至4%（p = 0.053）。
具有广泛导管内成分的肿瘤、40岁以下以及绝经后女性未使用辅助他莫昔芬会增加局部复发率。T2期及未进行腋窝淋巴结清扫会增加腋窝复发率。N +期以及局部或腋窝复发会增加远处失败率。腋窝放疗不影响局部区域控制及生存。复发患者需要改进治疗方法。
