腋淋巴结阳性乳腺癌结外侵犯的临床意义

Clinical impact of extracapsular extension of axiHary lymph node metastases in breast cancer

目的探讨乳腺癌患者淋巴结外侵犯（ECE）的临床意义。方法回顾性分析1230例腋窝淋巴结阳性乳腺癌，观察ECE与临床病理指标之间关系及对患者预后的影响。结果腋窝淋巴结阳性乳腺癌患者中，ECE阳性率为39．5％。绝经前和绝经后患者ECE的发生率分别为35．5％和47．5％（P〈0．001）。ECE阳性组和阴性组的肿瘤直径分别为5．11±2．53OITI和3．904-1．80cm（P〈0．001），肿瘤直径越大，ECE阳性比例越高（P〈0．001）。ECE阳性患者和ECE阴性患者的阳性淋巴结数目分别为16．96±12．16和5．24±6．60（P〈0．001），随腋窝阳性淋巴结数目增多，ECE阳性率明显增加（P〈0．001）。ECE的发生与ER、PR状态无显著相关（P=0．706）。ECE是乳腺癌患者局部或区域复发的危险因素（P〈0．001），复发时间差异无统计学意义（P=0．559）。ECE阳性组和ECE阴性组的远处转移时间分别为30．0个月和37．5个月（P=0．006）。首发骨、皮肤和远隔淋巴结组及内脏转移组的ECE阳性率分别为60．4％和42．0％（P=0．001）。ECE阳性患者的无转移生存时问、无局部或区域复发生存时间及总生存时间均小于ECE阴性患者。预后单因素和多因素分析显示，ECE是影响乳腺癌患者无转移生存时间、无局部或区域复发生存时间及总生存时间的独立危险因素。结论乳腺癌患者ECE的发生与肿瘤直径和受累淋巴结数目呈正相关；ECE是乳腺癌局部或区域复发和远处转移的危险因素；ECE是影响乳腺癌患者无转移生存时间、无局部或区域复发生存时间及总生存时间的危险因素。

Objective To study the clinical significance of extracapsular extension （ECE） of axillary lymph node metastases in breast cancer. Methods The clinicopathological data of 1230 cases of nodal positive breast cancer treated in our department from 1989 to 1995 were analyzed retrospectively. Results 486 （39.5%） from the 1230 cases were ECE positive. There was a higher incidence of ECE in postmenopausal women than premenopausal ones （47.5 % versus 35.5% , respectively, P 〈 0. 001 ）. The patients in ECE posotive group had a larger tumor size （ 5. 11 ± 2.53 cm versus 3.90 ± 1.80 cm, P 〈 0.001）. 18.3% of patients with stage T1 were ECE positive, stage T2 were 36.4%, and stage T3 were 54.4% ,and the difference was significant （P 〈 0. 001 ）. ECE was corelated with the number of positive axillary lymph nodes. The ECE positive group had more positive nodes than ECE negative group （ 16.96 ± 12.16 versus 5.24 ±6.60,P 〈0. 001 ）. 6.1% of patients with 1 positive node were ECE positive, 13.5% with 2-3, 35.8% with 4-9, 62.3% with 10-19, and 84.0% with more than 20 positive axillary nodes, and there was a significant difference among those groups （P 〈 0. 001 ）. ECE had no association with ER/PR status （P = 0. 706）. ECE was a risk factor of local-regional recurrence, but the relapse time had no significant difference （P = 0. 559）. ECE was also a risk factor of distant metastasis, and the relapse time had a significant difference （ P 〈0.001 ） . The median metastasis free time was 30.0 （2 - 172） months in ECE positive group, while 37.5 （2- 170） months in ECE negative group （P = 0. 006）. CE occurred in 60.4% of the patients with firstly diagnosed bone, skin and distant lymph node metastasis, but in 42.0% of the patients with firstly diagnosed visceral metastasis （ P = 0. 001 ）. The metastasis-free survival rate,locoregional recurrence-free survival rate and overall survival rate of the ECE positive group were much shorter than that of the ECE negative group. COX proportional hazard regression single factor analysis and multi-factor analysis suggested that ECE is an independent factor of metastasis-free survival, locoregional free recurrence and overall survival. Conclusion The presence of ECE in breast cancer is positively related with tumor size and the number of positive lymph nodes. It is also a risk factor of locoregional recurrence and distant metastasis. ECE positive group has a much shorter metastasis-free survival, locoregional recurrencefree survival and overall survival. ECE is a risk factor of those three indexes.