空芯针穿刺活组织检查与开放性手术活组织检查对乳腺癌手术质量及预后的影响

Impact of biopsy by core needle biopsy or open surgical biopsy on surgical quality and prognosis of breast cancer patients

目的探讨空芯针穿刺活组织检查（CNB）与传统的开放性手术活组织检查（OSB）对乳腺癌患者DFS的影响，同时评估两种活组织检查（简称活检）方式对乳腺癌手术质量的影响。方法回顾性分析2007年1月至2009年12月在广东省妇幼保健院乳腺病中心经CNB或OSB证实为乳腺癌的306例患者的临床资料，其中OSB组155例，CNB组151例。采用Kaplan—meier法对两组患者的DFS情况进行分析，并运用Cox回归模型探讨影响乳腺癌患者DFS的因素。同时以保留乳房率、保留乳房患者首次切缘阳性率、前哨淋巴结活检率及手术次数为指标，评价两种活检方式对乳腺癌手术质量的影响；计数资料比较采用r检验，计量资料比较采用t检验。结果全部患者的临床随访时间为29—83个月，中位随访时间为59个月。OSB组与CNB组中出现复发或转移的患者为分别为32例（20．6％，32／155）和29例（19．2％，29／151）。并且，OSB组局部复发率为4．5％（7／155），远处转移率为16．1％（25／155）；CNB组局部复发率为2．6％（4／151），远处转移率为16．5％（25／151）。两组患者间局部复发率及远处转移率的差异均无统计学意义（X^2=0．769、0．010，P=0．380、0．919）。Kaplan-meier生存分析显示，OSB组与CNB组间DFS差异无统计学意义（X^2=0．030，P=0．864）。Cox回归分析显示，淋巴结转移、ER及HER-2表达是影响乳腺癌患者DFS的主要因素（OR=2．458，95％CI：1．883—3．209，P=0．000；OR=0．453，95％CI：0．238—0．863，P=0．016；OR=2．086，95％CI：1．110～3．920，P=0．022），不同的活检方式并不影响乳腺癌患者的DFS。CNB组的保留乳房率明显高于OSB组[25．2％（38／151）比9．7％（15／155），X^2=12．812，P=0．000]，手术次数明显少于OSB组（1．00±0．00比1．35±0．48，t=9．090，P=0．000），但其前哨淋巴结活检率与OSB组的相比，差异无统计学意义[31．8％（48／151）比32．9％（51／155）,X^2=0．043，P=0．835]。并且，CNB组保留乳房患者的首次切缘阳性率与OSB组的保留乳房患者相比，差异也无统计学意义[10．5％（4／38）比5／15，0=2．515，P=0．113]。结论术前空芯针穿刺活检对患者的DFS无不良影响，并且可以明确诊断及分子分型，有利于手术方案及后续辅助治疗方案的制定，尽而提高乳腺癌的手术质量，不失为可扪及肿块乳腺癌的首选活检方法。

Objective To investigate the impact of core needle biopsy （CNB） and traditional open surgical biopsy （OSB） on disease-free survival and surgical quality of breast cancer patients. Methods We retrospectively analyzed the clinical data of 306 patients with breast cancer diagnosed by CNB or OSB in Breast Disease Center,Guangdong Women and Children＇ s Hospital from January 2007 to December 2009, including 155 cases in OSB group and 151 cases in CNB group. Kaplan-meier method was used to analyze disease-free survival in the two groups and Cox regression model was used to discuss the factors influencing the prognosis of the patients. Meanwhile the impact of different biopsy methods on the quality of breast cancer surgery was evaluated by the following parameters：breast-conserving rate, rate of positive margin in first breast-conserving surgery, rate of sentinel lymph node biopsy and times of surgeries. Count data were analyzed by Chi-square test, measurement data by t test. Results All the patients were followed up for 29 to 83 months （median 59 months）. Overall 32 cases（20.6% ,32/155） in OSB group and 29 cases（ 19.2% ,29/151 ） in CNB group had recurrence or metastasis. The local recurrence rate and distant metastasis rate was 4.5% （7/155） and 16. 1% （25/155） in OSB group,2.6% （4/151） and 16.5% （25/151） in CNB group,which indicated no significant difference between the two groups （X^2 = 0. 769,0. 010, P = 0. 380,0. 919 ）. Kaplan-meier survival analysis showed that there was no significant difference in disease-free survival between the two groups （X^2 = 0. 030,P = 0. 864）. Cox regression analysis showed that lymph node metastasis, ER and HER-2 expression were the major influencing factors in the prognosis of breast cancer patients （ OR = 2. 458, 95 % CI： 1. 883-3. 209, P = 0. 000 ; OR=0. 453,95% CI： 0. 238 -0. 863, P = 0. 016 ; OR = 2. 086,95% CI： l. 110-3. 920, P = 0. 022）, and the different methods of biopsy did not affect the disease-free survival. The breast-conserving rate was significantly higher in CNB group than that in OSB group [ 25.2% （38/151） vs 9.7% （15/155）, X^2 = 12. 812 ,P = 0.000 ], and the patients in CNB group had fewer operations compared with OSB group （ 1.00±0.00 vs 1.35 ±0.48, t = 9. 090, P = 0. 000）, but there was no significant difference in the rate of sentinel lymph node biopsy between the two groups [ 31.8 % （48/151 ） vs 32.9 % （ 51/155 ）, X^2 = 0.043, P = 0.835 ]. The rate of positive margin in first breast-conserving surgery showed no signifieant difference between CNB group and OSB group [ 10.5% （4/38） vs 5/15, X^2 =2. 515, P = 0. 113 ]. Conclusion Preoperative CNB can provide guidance for the diagnosis, molecular typing and the selection of surgical and subsequent adjuvant treatment plans so as to improve the quality of breast cancer surgery, without adverse effects on disease-free survival of breast eaneer patients, which can be regarded as the first choice for the patients with palpable breast mass.