三阴性乳腺癌TNM分期的临床特点及影响预后的危险因素

Clinical features of TNM staging of triple negative breast cancer and risk factors affecting its prognosis

目的探讨三阴性乳腺癌(TNBC)TNM分期的临床特点及影响预后的独立危险因素。方法收集2005年1月至2007年6月在本院经临床诊断并手术病理证实的429例女性乳腺癌患者。TNBC患者98例,其余331例为非三阴性乳腺癌(NTNBC)患者。按照IUCC/AJCC第6版乳腺癌TNM分期标准两组患者进行分期并对比分析。病理生物学行为和TNM分期的比较采用χ2检验或秩和检验。生存分析采用Kaplan-Meier法、绘制生存曲线。影响TNBC预后的危险因素分析采用Cox比例风险回归模型。结果本组TNBC占同期乳腺癌的22.84%(98/429),NTNBC占77.16%(331/429)。TNBC组与NTNBC组比较,在肿瘤组织学分级(Ⅲ级41.84%比21.45%)、组织病理学分类(浸润性导管癌73.47%比59.82%)、术后肿瘤局部复发(27.55%比13.29%)、肿瘤大小(直径>5cm,41.84%比25.08%)、区域淋巴结转移(56.12%比39.88%)和远处脏器转移(25.51%比12.69%)的差异均有显著的统计学意义(P<0.050)。在TNM分期中,TNBC组与NTNBC组比较,Ⅰ期(8.16%比16.01%)、Ⅱa期(17.35%比26.28%)、Ⅱb期(17.35%比26.89%),差异无统计学意义(P>0.050);而在Ⅲa期(24.49%比15.71%)、Ⅲb期(12.25%比6.04%)、Ⅲc期(9.18%比3.93%)和Ⅳ期(11.22%比5.14%),TNBC组所占的比例高于NTNBC组(P<0.050)。TNBC组与NTNBC组比较,5年总生存率(76.53%比89.73%)和5年无瘤生存率(63.27%比74.32%)差异有显著统计学意义(P<0.050)。TNBC组的中位生存期为54.08个月(95%CI48.880～59.283),NTNBC组为59.00个月(95%CI51.515～63.849)。影响TNBC预后的独立危险因素Cox回归分析结果显示,TNM分期中的Ⅲ、Ⅳ期、区域淋巴结转移和远处脏器转移是影响TNBC患者预后的独立危险因素。结论乳腺癌TNM分期能够反映TNBC的侵袭性和复发转移的临床特点,Ⅲ期、Ⅳ期和区域淋巴结转移以及远处脏器转移是影响TNBC预后的独立危险因素,其中远处脏器转移是导致TNBC患者死亡最主要的危险因素。

Objective To analyze the clinical features of TNM staging of triple negative breast cancer （TNBC） and risk factors affecting its prognosis. Methods From January 2005 to June 2007 a total of 429 breast cancer patients confirmed pathologically after operation in our hospital were collected in this study. Among them 98 patients were diagnosed as triple negative breast cancer （TNBC） and the rest 331 as non-triple negative breast cancer （NTNBC）. All patients were staged according to the staging system （IUCC/AJCC, the 6th edition ） and the two groups of patients were compared and analyzed. Comparison of pathobiological behaviours and TNM stages between the two groups was done using chi-square test or rank sum test. Kaplan- Meier method, drawing survival curve and Log-rank test were used for survival analysis. Cox regression was used for analysis of death risk factors for TNBC patients. Results TNBC patients accounted for 22. 84% （98/429） and NTNBC for 77. 16% （331/429）. The comparison between the TNBC group and the NTNBC group showed significantly statistical difference in histology grade （grade HI, 41.84% vs 21.45% ）, pathobiological types （invading ductal cancer, 73.47% vs 59. 82% ）, local recurrence after operation （27.55% vs 13.29% ）,tumor diameter（ maximum diameter of primary tumor 〉5 cm,41.84% vs 25.08% ）, metastasis of lymph nodes （56. 12% vs 39. 88% ） and organ metastasis （25.51% vs 12. 69% ） （P〈0. 050）. The comparison of TNM stage between the TNBC group and the NTNBC group showed no statistical difference in stage Ⅰ （8. 16% vs 16. 01% ）, stage Ⅱa （17.35% vs 26. 28%） and stage Ⅱb （17.35% vs 26. 89%） （P〉 0. 050） ,but significant difference in stage Ⅲa （24. 49% vs 15.71% ） ,stage Ⅲb （12.25% vs 6.04% ） ,stage Ⅲc （9. 18% vs 3.93%） and stage Ⅳ （11.22% vs 5.14%） （P〈0.050）. The 5-year overall survival and disease free survival in the TNBC group was markedly lower than in the NTNBC group （ 76. 53% vs 89.73% and 63.27% vs 74. 32% ） （ P〈0. 050）. The median survival time was 54. 082 months （95% C1 48. 880 59. 283） in the TNBC group and 59. 000 months （95 % C1 51.515 - 63. 849） in the NTNBC group. TNM stage Ⅲ, Ⅳ （ χ2 = 5. 094, P = 0. 024） and lymph node metastasis （ χ2 = 4. 375, P = 0. 036） and organ metastasis （ χ2 = 6. 064,P= 0. 012 ） were the risk factors affecting the prognosis of TNBC patients. Conclusion The TNM staging system for breast cancer well reflect the clinical features of invasion, recurrence and metastasis of TNBC. TNM stage Ⅲ and Ⅳ, lymph node metastasis and organ metastasis are dependent factors affecting the prognosis, and distant metastasis is the most important factor of death for TNBC.