早期乳腺癌乳房保留治疗的疗效分析

Outcome of breast-conservative therapy for early-stage breast cancer： a retrospective analysis

目的评价早期乳腺癌保乳术后令乳放疗的生存率和局部．区域控制率，探讨影响局部控制的因素。方法近10年收治的早期乳腺癌接受保乳术者335例，其中术后单纯放疗、序贯化放疗、同期放化疗、化放化疗分别为25、194、80、36例。312例接受腋窝淋巴结清扫，2例前哨淋巴结活枪。310例接受辅助化疗。256放疗范围为单纯乳房，79例包括区域淋巴结照射。全乳和区域淋巴结照射剂最为50Gy分25次，中位瘤床剂量为60Gy分30次。放疗和手术间隔时间〈4、4～8、〉8—20、〉20周的比例分别为16．4％、23．6％、37．3％、22．7％。结果中位随访期48．0个月（25．3—146．7个月）。5年局部-区域控制率和同侧乳房控制率分别为94．5％和95．6％；5年无病生存率、无转移生存率和总生存率分别为88．6％、93．2％和98．8％。单因素分析发现脉管受侵、神经受侵犯和Ⅱ期切除的5年局部控制率下降，手术与放疗间隔时间、化疗与放疗结合方式的局部控制率均相似。多因素分析发现脉管侵犯和Ⅱ期切除是独赢的预后因素。序贯化放疗＋单纯放疗、同期放化疗、化放化疗≥3级皮肤反应（湿性脱皮）发生率分别为4．5％、80．0％、77．0％（X^2=226．00，P=0．000）。结论早期乳腺癌保乳术加术后全乳放疗等可获得良好的局部控制率和生存率。脉管受侵与否和Ⅱ期切除是影响局部控制率的独立预后因素。未发现手术与放疗间隔时间、放疗与化疗结合方式对局部控制率有影响，但同期放化疗或化放化疗者发生皮肤湿性脱皮的概率明显增高。

Objective To analyze the results of survival and local regional control of early-stage breast cancer patients treated with breast-conserving surgery and whole breast radiation therapy, and to explore the factors influencing local control. Methods From October 1995 to September 2005,335 patients with early-stage breast cancer were treated with breast conservative therapy,including 25 with post-operative radiotherapy alone（ group A）, 194 with sequential chemo-radiotherapy（ group B）, 80 with concurrent chemoradiotherapy（group C）, and 36 with chemo-radio-chemotherapy（group D）. Axillary dissection was performed in 312 patients and sentinel node biopsy in 2. Adjuvant chemotherapy was given to 310 patients. Radiation of 50 Gy in 25 fractions was delivered to the whole breast in 256 patients, and to the breast and regional nodes in 79. Another 10 Gy in 5 fractions was boosted to the tumor bed. The proportion of patients with surgery-radiation interval of less than 4 weeks,4-8 weeks,8-20 weeks and over 20 weeks was 16.4% , 23.6% ,37.3% and 22.7%, respectively. Concurrent chemo-radiation and＂ sandwich＂ modality were delivered in 80 and 36 patients, respectively. Results The median follow-up was 48 （25.3-146.7） months. The 5-year local-regional control and ipsilateral breast control rates were 94.5% and 95.6% , respectively. The 5-year disease-free survival,metastasis-fi＇ee survival and overall survival rates were 88.6% ,93.2% and 98.8% ,respectively. Lymph-vascular invasion and neural invasion were significant factors influencing local control in univariate analysis. No significant differences were found in local control rates among different surgery-radiation intervals or different sequencing of radiotherapy and chemotherapy. Multivariate analysis showed that lymph-vascular invasion and reexcision for positive or unknown margin were independent prognostic factors influencing local control. In group A ＋ B,C and D,the frequency of grade m skin toxicity was4.5% ,80.0% ,and 77.0%, respectively （ X^2 = 226.00, P = 0. 000）. Conclusions Breast conservative therapy for early-stage breast cancer results in good local-regional control and overall survival. Lymph-vascular invasion and reexcision are independent prognostic factors for local control. Surgery-radiation interval and sequencing of radiotherapy and chemotherapy have no impact on local control. Grade Ⅲ skin toxicity of the concurrent radio-chemotherapy and the chcmo-radio-chemothcrapy group is significantly higher than that of the sequential chemotherapy-radiotherapy plus radiotherapy alone group.