不同治疗方式对三阴性乳腺癌预后的影响

Effects of different treatments on prognosis of triple-negative breast cancer

目的分析0~Ⅲ期三阴性乳腺癌(TNBC)患者的临床病理特征及不同治疗方式对5年总生存(OS)率和5年无瘤生存(DFS)率的影响。方法收集2004年1月至2013年12月解放军总医院第五医学中心普通外科二病区治疗的209例0~Ⅲ期TNBC患者资料,回顾性分析其临床特征及治疗方式与患者5年OS率和5年DFS率的相关性。采用Kaplan-Meier法绘制生存曲线,Cox比例风险模型进行多因素分析。结果单因素分析发现,TNBC临床分期和手术方式与患者5年OS率(χ^(2)=52.615,P<0.001;χ^(2)=17.329,P=0.001)和5年DFS率(χ^(2)=55.112,P<0.001;χ^(2)=18.816,P<0.001)有关。多因素分析显示,临床分期是TNBC患者DFS(HR=3.637,95%CI为2.146~6.164,P<0.001)和OS(HR=3.545,95%CI为2.091~6.009,P<0.001)的独立预后因素。对于腋窝淋巴结未转移的TNBC(n=118),保乳+前哨淋巴结活检术、乳房全切+前哨淋巴结活检术、改良根治术、保乳+腋窝淋巴结清扫术患者的5年OS率分别为97.6%、97.7%、91.4%、100%,5年DFS率分别是97.3%、94.3%、85.8%、100%,差异均无统计学意义(χ^(2)=3.369,P=0.338;χ^(2)=3.868,P=0.276)。行新辅助化疗患者(n=106)与行辅助化疗患者(n=80)5年OS率分别为74.5%、91.1%,5年DFS率分别为73.6%、86.8%,差异均有统计学意义(χ^(2)=4.504,P=0.034;χ^(2)=4.683,P=0.030)。新辅助化疗患者的临床分期更晚(χ^(2)=35.314,P<0.001)。相同临床分期的患者行新辅助化疗和辅助化疗的5年OS率和5年DFS率差异均无统计学意义(均P>0.05)。新辅助化疗获得病理完全缓解(pCR)、部分缓解(PR)和病情稳定(SD)患者的5年OS率分别为100%、75.8%、57.1%,5年DFS率分别为100%、74.5%、55.7%,差异均具有统计学意义(χ^(2)=10.086,P=0.006;χ^(2)=10.399,P=0.006);pCR患者和PR患者相比,5年OS率(χ^(2)=4.238,P=0.040)和5年DFS率(χ^(2)=4.525,P=0.033)差异均有统计学意义;pCR患者和SD患者相比,5年OS率(χ^(2)=8.163,P=0.004)和5年DFS率(χ^(2)=8.509,P=0.004)差异均有统计学意义;PR患者和SD患者相比,5年OS率(χ^(2)=3.931,P=0.047)和5年DFS率(χ^(2)=3.896,P=0.048)差异均有统计学意义。结论临床分期是0~Ⅲ期TNBC患者的独立预后因素。对腋窝淋巴结未转移的患者,行保乳+前哨淋巴结活检术、乳房全切+前哨淋巴结活检术、改良根治术以及保乳+腋窝淋巴结清扫术预后相当。相同临床分期的患者新辅助化疗与辅助化疗预后没有明显差异,但新辅助化疗获得pCR或者PR的患者能够获得较好的生存。

Objective To analyze the clinical features and the effects of different treatments on 5-year overall survival(OS)rate and 5-year disease free survival(DFS)rate of stage 0-Ⅲtriple-negative breast cancer(TNBC).Methods The data of 209 patients diagnosed as stage 0-ⅢTNBC in Ward 2 of Department of General Surgery of the Fifth Medical Center of PLA General Hospital from January 2004 to December 2013 were selected.The relationships between the clinical features,treatments and 5-year OS rate,5-year DFS rate were retrospectively analyzed.Kaplan-Meier method was used to draw survival curves,and Cox proportional risk model was used for multivariate analysis.Results Univariate analysis found that clinical stage and methods of surgery were associated with 5-year OS rate(χ^(2)=52.615,P<0.001;χ^(2)=17.329,P=0.001)and 5-year DFS rate(χ^(2)=55.112,P<0.001;χ^(2)=18.816,P<0.001).Multivariate analysis showed that clinical stage was an independent prognostic factor of DFS(HR=3.637,95%CI:2.146-6.164,P<0.001)and OS(HR=3.545,95%CI:2.091-6.009,P<0.001).For the TNBC patients without axillary lymph node metastasis(n=118),the 5-year OS rates of patients with breast conservation surgery+sentinel lymph node biopsy,total breast resection+sentinel lymph node biopsy,modified radical mastectomy and breast conserving surgery+axillary lymph node dissection were 97.6%,97.7%,91.4%,100%respectively,the 5-year DFS rates were 97.3%,94.3%,85.8%,100%respectively,and there were no significant differences among the four groups(χ^(2)=3.369,P=0.338;χ^(2)=3.868,P=0.276).The 5-year OS rate(74.5%vs.91.1%)and 5-year DFS rate(73.6%vs.86.8%)were significantly different in patients receiving neoadjuvant chemotherapy(n=106)compared with those receiving adjuvant chemotherapy(n=80)(χ^(2)=4.504,P=0.034;χ^(2)=4.683,P=0.030).The patients receiving neoadjuvant chemotherapy had later clinical stages than those receiving adjuvant chemotherapy(χ^(2)=35.314,P<0.001).There were no significant differences in 5-year OS rate and 5-year DFS rate between the patients receiving neoadjuvant chemotherapy and adjuvant chemotherapy with the same clinical stage(all P>0.05).The 5-year OS rates of patients with pathologic complete response(pCR),partial response(PR)and stable disease(SD)obtained by neoadjuvant chemotherapy were 100%,75.8%and 57.1%respectively,and the 5-year DFS rates were 100%,74.5%and 55.7%respectively,with statistically significant differences(χ^(2)=10.086,P=0.006;χ^(2)=10.399,P=0.006).Between the pCR group and the PR group,the 5-year OS rate(χ^(2)=4.238,P=0.040)and 5-year DFS rate(χ^(2)=4.525,P=0.033)were significantly different.Between the pCR group and the SD group,the 5-year OS rate(χ^(2)=8.163,P=0.004)and 5-year DFS rate(χ^(2)=8.509,P=0.004)were significantly different.Between the PR group and the SD group,the 5-year OS rate(χ^(2)=3.931,P=0.047)and 5-year DFS rate(χ^(2)=3.896,P=0.048)were significantly different.Conclusion For the patients with stage 0-ⅢTNBC,clinical stage is an independent prognostic factor.For the TNBC patients without axillary lymph node metastasis,breast conservation surgery+sentinel lymph node biopsy,total breast resection+sentinel lymph node biopsy,modified radical mastectomy and breast conserving surgery+axillary lymph node dissection have similar outcomes.There is no significant difference between neoadjuvant chemotherapy and adjuvant chemotherapy in the prognosis of patients with the same clinical stage,but patients with pCR or PR obtained by neoadjuvant chemotherapy can achieve better survival.