Ⅱ期乳腺癌患者腋窝淋巴结结外侵犯截点值的分析

Analysis of the cut-off value of extranodal invasion of axillary lymph node in patients with stageⅡbreast cancer

目的探讨Ⅱ期乳腺癌阳性腋窝淋巴结结外侵犯(extranodal extension,ENE)的临床意义及影响预后的ENE垂直直径的截点值。方法回顾性分析河北医科大学第四医院2008年1月1日~2012年12月31日存档的原发非特殊型浸润性乳腺癌改良根治手术标本287例,所有患者均有1~3枚腋窝淋巴结转移,镜下观察腋窝淋巴结转移及ENE情况,测量ENE的垂直直径,结合其他临床病理特征分析其对患者预后的影响。结果287例中有ENE者80例,阳性率为27.9%,ENE的垂直直径中位数为2.5 mm(0.5~12 mm)。肿瘤直径越大、临床分期越晚、淋巴结转移数越多,ENE的发生率越高;ER阴性者比阳性者发生率更高(P<0.05)。Kaplan-Meier单因素生存分析结果显示,腋窝淋巴结ENE阳性患者的5年无瘤生存(disease free survival,DFS)率及总生存(overall survival,OS)率分别为55.8%和84.4%,低于阴性组的90.6%和95.1%,5年DFS和OS时间均缩短,差异有统计学意义(P<0.05)。Cox多因素生存分析结果显示,ENE阳性、HER-2阳性、分子分型是影响Ⅱ期乳腺癌患者DFS和OS的独立危险因素;ER阳性患者与较好的预后相关。以ENE垂直直径3 mm为截点,>3 mm是影响患者DFS和OS的独立危险因素,与≤3 mm组相比,对5年DFS及OS影响的相对危险度分别为4.251(95%CI:2.382~7.586)和2.806(95%CI:1.146~6.883)。结论腋窝淋巴结ENE可能是Ⅱ期乳腺癌不良预后的指标之一。ENE垂直直径是预后影响因素的独立预测指标,ENE垂直直径>3 mm有望作为乳腺癌患者预后风险预测的截点值应用于临床诊疗决策。

Purpose To investigate the clinical significance of extranodal extension(ENE)of positive axillary lymph node in stageⅡbreast cancer and the cut-off value of the vertical diameter affecting prognosis.Methods 287 cases of modified radical mastectomy specimens of primary non-specific invasive breast cancer filed in the department of pathology,the Fourth Hospital,Hebei Medical University from January 1,2008 to December 31,2012 were analyzed retrospectively.All patients had 1 to 3 axillary lymph nodes metastasis.The metastasis of axillary lymph nodes and ENE were observed under microscope,and the vertical diameter of ENE was measured,and its effect on prognosis was analyzed combining other clinicopathological parameters.Results Of the 287 patients,ENE was present in 80 patients(27.9%).The median vertical diameter of ENE was 2.5 mm(0.5-12 mm).The incidence of ENE increased with the enlargement of the maximum diameter of tumors,the later of clinical stage and the increase of lymph node metastasis,and the frequency of ENE in ER negative patients was higher than that in ER positive patients(P<0.05).Kaplan-Meier univariate survival results showed that 5-year disease free survival(DFS)rate and 5-year overall survival(OS)rate were 55.8%and 84.4%in ENE positive axillary lymph nodes,which were lower than that in negative lymph nodes(90.6%and 95.1%).The 5-year DFS and OS time were shortened,and the difference was statistically significant(P<0.05).Cox multivariate survival analysis showed that ENE positive,HER-2 positive and molecular typing were independent risk factors for DFS and OS in patients with stageⅡbreast cancer.ER positive patients were associated with better prognosis.Compared with≤3 mm group,the relative risk of 5-year DFS and OS was 4.251(95%CI:2.382-7.586)and 2.806(95%CI:1.146-6.883).Conclusion The presence of ENE in axillary lymph nodes may be one of the indicators of poor prognosis in stageⅡbreast cancer.The vertical diameter of ENE is an independently prognostic marker.The vertical diameter of ENE>3 mm is expected to be used as a cut-off point for predicting the prognostic risk of breast cancer patients in clinical diagnosis and treatment decisions.