乳腺癌全乳房切除术后单纯区域复发的放疗和预后分析

Radiotherapy and prognostic analysis of breast cancer patients with isolated regional recurrence after mastectomy

目的分析乳腺癌全乳房切除术后单纯区域复发(RR)患者的预后,探讨放疗的价值和靶区。方法回顾性分析2001—2018年间144例全乳房切除术后无辅助放疗、首次孤立性RR的乳腺癌患者,主要研究终点为再次局部区域复发(sLRR)、远处转移(DM)、无进展生存(PFS)和总生存(OS)。结果RR后中位随访82.5个月,全组患者5年sLRR、DM、PFS和OS分别为42.1%、71.9%、22.9%和62.6%。局部治疗+全身治疗是sLRR(P<0.001)和PFS(P=0.013)的独立影响因素。局部治疗时手术+放疗组的sLRR率最低(P<0.001)。手术+放疗组的5年原RR部位再次复发率最低(P<0.001)。做和不做胸壁放疗患者的5年胸壁复发率分别为12.1%和14.8%(P=0.873)。非锁骨上复发者,做和不做锁骨上放疗的5年锁骨上复发率分别为9.9%和23.8%(P=0.206)。非腋窝或内乳复发者,无论放疗与否,腋窝或内乳的5年复发率均<10%。结论单纯RR患者有较高的5年OS,推荐对复发部位行手术+放疗的局部治疗联合全身治疗。不建议常规对所有患者行胸壁、腋窝或内乳的预防放疗。锁骨上预防性放疗的价值需要进一步探讨。

Objective To analyze the prognosis of patients with isolated regional recurrence(RR)after mastectomy,and evaluate the efficacy of radiotherapy and identify the optimal radiation target volumes.Methods Clinical data of 144 patients with first isolated RR after mastectomy between 2001 and 2018 were retrospectively analyzed.All patients had not received post-mastectomy radiotherapy.The primary endpoints consisted of the subsequent locoregional recurrence(sLRR),distant metastasis(DM),progression-free survival(PFS)and overall survival(OS).Results With a median follow-up of 82.5 months after RR,the 5-year sLRR,DM,PFS and OS rates for the entire group were 42.1%,71.9%,22.9%and 62.6%,respectively.Local plus systemic therapy was an independent favorable prognostic factor for sLRR(P<0.001)and PFS(P=0.013).The sLRR rate in the surgery plus radiotherapy group was the lowest(P<0.001).Surgery plus radiotherapy significantly reduced the 5-year risk of recurrence within the initially involved nodal regions(P<0.001).Patients with chest wall irradiation obtained the 5-year subsequent chest wall recurrence rate of 12.1%compared to 14.8%(P=0.873)for those without chest wall irradiation.The subsequent supraclavicular recurrence rate was lower in patients with prophylactic supraclavicular irradiation than that without prophylactic supraclavicular irradiation(9.9%vs.23.8%,P=0.206).The incidence rates of initially uninvolved axillary and internal mammary nodal recurrence were below 10%regardless of prophylactic irradiation or not.Conclusions Patients with RR alone have an optimistic 5-year OS in the contemporary era.Comprehensive locoregional treatment including surgery and radiotherapy combined with systemic therapy is recommended.The chest wall,axillary and internal mammary nodal prophylactic irradiation should not be routinely performed for all patients with RR.The value of supraclavicular prophylactic irradiation remains to be evaluated.