乳腺癌成骨转移的诊断和治疗

Diagnosis and treatment of osteoblastic metastasis in patients with breast cancer

乳腺癌成骨转移相对少见，但是临床上时有误诊误治的患者。成骨转移只能通过X线或CT骨窗扫描得以诊断，但还需与溶骨或混合性转移治疗有效的成骨修复患者相鉴别。成骨转移常发生于乳腺癌的无病状态，罕见于术前Ⅳ期病变患者。本文透过临床现象，对世界卫生组织和美国MD安德森癌症治疗中心制订的乳腺癌骨转移疗效评价标准提出质疑，并推断成骨转移的形成机制。对单纯成骨转移患者，突破美国国家综合癌症网络指南的建议，提倡无为而治的理念。激素受体阳性患者当然适用内分泌治疗，可继续沿用原来辅助内分泌药物；激素受体阴性和（或）人表皮生长因子受体2阳性患者，先不治疗，待出现溶骨或内脏转移时再用化疗和（或）靶向治疗。因为成骨转移一般不存在骨相关事件的风险，不需要用双膦酸盐。术前Ⅳ期患者还应首先顾及原发病灶的积极治疗。

Osteoblastic metastasis of breast cancer is relatively rare, but there are cases of misdiagnosis and mistreatment in clinical treatment. They can only be diagnosed by X ray or CT bone scan and must be identified from bone repair after effective treatment in patients with osteolytic or mixed bone metastases. Bone metastasis is often seen in the disease-free condition of breast cancer, and very few can occur in stage Ⅳ lesions prior to surgery. Based on the analysis of clinical phenomena, we questioned the evaluation criteria of the therapeutic effect on bone metastasis of breast cancer created by the World Health Organization and the MD Anderson Cancer Center and concluded the formation mechanism of bone metastasis. For patients with simple osteoblastic bone metastasis, we broke through the recommendations of the National Comprehensive Cancer Network guideline and advocated the concept of ＂noninterference＂ . Patients with positive hormone receptor can be treated with traditional endocrine therapy. Hormone receptor negative and/or human epidermal growth factor receptor 2 positive patients can be observed first, followed by chemotherapy and/or targeted therapy when there is osteolytic bone metastasis or visceral metastasis. Furthermore, bisphosphonates are not required since osteoblastic bone metastasis is generally not associated with the risk of bone related events. The active treatment of primary lesion should be taken into account in stage Ⅳ patient before operation.