乳腺癌新辅助化疗后临床评价与病理评价的差异分析

Differences between clinical response and pathologic response of breast cancer after neoadjuvant chemotherapy

目的 探讨乳腺癌新辅助化疗后,临床疗效评价与病理评价之间存在差异的病理学基础.方法 收集中国医学科学院肿瘤医院2005年6月至2007年12月施行乳腺癌新辅助化疗的209例.新辅助化疗前均行核芯针穿刺活检.化疗结束后4周内实施乳腺癌根治术.新辅助化疗前后均对乳腺原发灶进行临床体检、乳腺X线检查和（或）超声检查.实施新辅助化疗后,依实体瘤的疗效评价标准（RECIST,1.1版）对乳腺癌原发灶进行临床疗效评价,依Miller和Payne（MP）分级系统进行病理评价.应用SPSS 15.0软件分析临床评价与病理评价的相关性.结果 （1）新辅助化疗后依临床体检结果进行临床评价：完全缓解33例,部分缓解124例,疾病稳定41例,疾病进展11例.（2）新辅助化疗前后均行乳腺X线检查87例,依乳腺X线检查进行临床评价：完全缓解8例,部分缓解42例,疾病稳定37例.（3）新辅助化疗后MP分级病理评价：1级14例,2级35例,3级106例,4级36例,5级18例.（4）临床体检相关的临床评价与病理评价存在统计学相关性（χ^2=33.668,P=0.001）,乳腺X线检查相关的临床评价与病理评价存在统计学相关性（χ^2=22.404,P=0.004）.（5）新辅助化疗病理评价与X线检查相关临床评价存在差异的病理学改变有：残存浸润癌以脉管瘤栓为主要表现形式;伴有大片黏液湖形成的黏液腺癌;导管内癌残存,伴明显沙砾样钙化及周围组织的沙砾样钙化;间质结节状纤维化等.结论 乳腺癌新辅助化疗的临床评价与病理评价存在统计学相关性.两者之间的差异有相应的病理学基础.伴有大片黏液湖形成的黏液腺癌、导管内癌的残存伴沙砾样钙化及间质结节状纤维化可能是临床评价低估治疗疗效的原因之一;而残存癌表现为脉管瘤栓可能是临床评价高估治疗疗效的原因之一.

Objective To investigate the pathologic basis of the difference between clinical response and pathologic response of breast carcinoma after neoadjuvant chemotherapy. Methods Two hundred and nine cases of breast cancer with neoadjuvant therapy were analyzed and clinical data were collected from June, 2005 to December, 2007. All patients had core needle biopsy taken before neoadjuvant chemotherapy and were operated within 4 weeks after neoadjuvant chemotherapy. Clinical examination, X-ray of breast and/or B ultrasonography of primary breast focus were taken before and after neoadjuvant chemotherapy. Clinical responses of breast primary focus were evaluated according to RECIST （response evaluation criteria in solid tumors） version 1.1. Pathologic responses of breast primary focus were evaluated according to Miller and Payne （MP） grading system. SPSS 15.0 software was used to statistical analysis. Results （1）Clinical responses basing on clinical examination showed complete response, partial response, stable disease and progressive response, in 33, 124, 41 and 11 cases respectively. （2） Eighty-seven cases had X-ray of breast taken before and after neoadjuvant chemotherapy. Clinical response basing on X-ray, showed complete response, partial response and stable disease in 8, 42 and 37 cases respectively. （3） Pathologic responses of breast primary focus were as MP1 （14 cases）, MP2 （35 cases）, MP3 （106 cases）, MP4 （36 cases） and MP5 （18 cases）. （4） The clinical response basing on clinical examination were related to the pathologic response （χ^2 = 33.668, P = 0.001）; and the clinical response basing on X-ray of breast were also related to the pathologic response （χ^2 = 22.404, P = 0.004）. （5） The pathologic basis of the difference between the pathologic response and the clinical response basing on X-ray of breast were： embolism of carcinoma, mucinons carcinoma, intraductal carcinoma with ossifying-type calcification, nodular fibrosis and others. Conclusions The clinical response may be related to the pathologic response. The difference between the two may be caused by pathologic changes. Some benign and malignant pathologic changes may contribute to the under-estimation of clinical response over pathologic response; whereas embolism of carcinoma may contribute to the over-estimation of clinical response over pathologic response.