Fisher B J, Perera F E, Cooke A L, Opeitum A, Dar A R, Venkatesan V M, Stitt L, Radwan J S
Department of Radiation Oncology, London Regional Cancer Centre and University of Western Ontario, Canada.
Int J Radiat Oncol Biol Phys. 1997 Jun 1;38(3):551-9. doi: 10.1016/s0360-3016(97)89483-7.
This is a retrospective review into the patterns of failure of 82 patients with Stage II or III breast cancer who had extracapsular extension (ECE) of axillary nodal metastases and who received systemic chemotherapy or hormonal therapy without loco-regional radiation.
The clinical records of patients with axillary node positive (T1-T3, N1, 2) Stage II or III breast cancer seen at the London Regional Cancer Centre between 1980-1989 were reviewed. Patients were identified who underwent segmental mastectomy with axillary node dissection or modified radical mastectomy and received adjuvant chemotherapy or tamoxifen but did not undergo loco-regional radiation. Eighty-two patients within this group had pathologic evidence of extracapsular axillary node extension (ECE). For 45 of these patients the extension was extensive, and for the remaining 37 it was microscopic. This ECE-positive group was compared to a subgroup of 172 patients who did not have pathologic evidence of extracapsular axillary node extension but had metastatic carcinoma confined within the nodal capsule.
Median age of the 82 ECE-positive patients was 56 years. Twenty-five patients had had a segmental mastectomy, the remainder a modified radical mastectomy. Median actuarial survival was 60 months, with a median disease-free and loco-regional failure-free survival of 38 months. Seventy-eight percent of these patients developed a recurrence, which was loco-regional in 60% (21% local, 21% regional, 2% local and regional, and 16% loco-regional and metastatic). There was a 36% recurrence rate in intact breast, 14% the chest wall following modified radical mastectomy, 7% relapsed in the axilla, 12% in supraclavicular nodes, and 1% in the internal mammary nodes. A comparison of the 82 ECE-positive patients with a group of 172 ECE-negative patients determined that there was a statistically significant difference between the two groups in terms of survival (overall and disease-free) and loco-regional recurrence. Univariate analysis of the entire 254 node-positive patient group revealed extracapsular nodal extension (ECE) to be a prognostically significant factor for actuarial and disease-free survival as well as for loco-regional failure, but ECE did not remain an independently prognostic factor after multivariate analysis. Segmental mastectomy, positive resection margins, and ER negative status increased the risk of loco-regional recurrence within the ECE-positive group.
Extracapsular axillary node extension is a prognostically significant factor for actuarial survival, disease-free survival, and loco-regional failure but not independent of other adverse prognostic factors. It is a marker for increased loco-regional recurrence associated with doubling of breast, chest wall, and supraclavicular recurrence rates. The risk of axillary relapse in patients who have had an adequate level I and II axillary dissection but demonstrate extracapsular extension is low (7%). We recommend breast/chest wall and supraclavicular radiation for all patients with pathologic evidence of such extranodal extension who have had a level I and II axillary dissection regardless of the number of positive axillary nodes. Axillary irradiation should be considered for patients who have had only an axillary sampling or level I axillary dissection.
本研究对82例II期或III期乳腺癌患者的失败模式进行回顾性分析，这些患者存在腋窝淋巴结转移的包膜外扩展（ECE），且接受了全身化疗或激素治疗，但未接受局部区域放疗。
回顾了1980年至1989年间在伦敦地区癌症中心就诊的腋窝淋巴结阳性（T1-T3，N1、2）II期或III期乳腺癌患者的临床记录。确定接受了保乳手术加腋窝淋巴结清扫或改良根治性乳房切除术并接受辅助化疗或他莫昔芬治疗但未接受局部区域放疗的患者。该组中有82例患者有腋窝淋巴结包膜外扩展（ECE）的病理证据。其中45例患者的扩展范围广泛，其余37例为镜下扩展。将这一ECE阳性组与172例没有腋窝淋巴结包膜外扩展的病理证据但转移癌局限于淋巴结包膜内的患者亚组进行比较。
82例ECE阳性患者的中位年龄为56岁。25例患者接受了保乳手术，其余患者接受了改良根治性乳房切除术。中位精算生存率为60个月，中位无病生存和局部区域无失败生存率为38个月。这些患者中有78%出现复发，其中60%为局部区域复发（21%为局部复发，21%为区域复发，2%为局部和区域复发，16%为局部区域和远处转移复发）。保乳患者的复发率为36%，改良根治性乳房切除术后胸壁复发率为14%，腋窝复发率为7%，锁骨上淋巴结复发率为12%，内乳淋巴结复发率为1%。将82例ECE阳性患者与172例ECE阴性患者组进行比较，结果显示两组在生存（总生存和无病生存）和局部区域复发方面存在统计学显著差异。对整个254例淋巴结阳性患者组进行单因素分析发现，淋巴结包膜外扩展（ECE）是精算生存、无病生存以及局部区域失败的一个预后显著因素，但多因素分析后ECE不再是一个独立的预后因素。在ECE阳性组中，保乳手术、切缘阳性和雌激素受体阴性状态增加了局部区域复发的风险。
腋窝淋巴结包膜外扩展是精算生存、无病生存和局部区域失败的一个预后显著因素，但并非独立于其他不良预后因素。它是局部区域复发增加的一个标志，与乳房、胸壁和锁骨上复发率翻倍相关。在进行了充分的I级和II级腋窝清扫但显示有包膜外扩展的患者中，腋窝复发风险较低（7%）。我们建议，对于所有有这种结外扩展病理证据且已进行I级和II级腋窝清扫的患者，无论腋窝阳性淋巴结数量多少，均应进行乳房/胸壁和锁骨上放疗。对于仅进行了腋窝取样或I级腋窝清扫的患者，应考虑进行腋窝放疗。
