T_(1-2)N_(1mi)M_(0)期乳腺癌患者乳房切除术后前哨淋巴结微转移的处理

Management of sentinel lymph node micrometastases after mastectomy in patients with T_(1-2)N_(1mi)M_(0)breast cancer

目的:探讨乳房切除术后不同腋窝处理方式对T_(1-2)N_(1mi)M_(0)期乳腺癌患者乳腺癌特异性生存率(BCSS)的影响。方法:本研究为回顾性队列研究,分析了SEER数据库中2010—2019年3871例病理诊断为T_(1-2)N_(1mi)M_(0)期单侧浸润性乳腺导管癌并行乳房切除的患者数据。根据患者术后腋窝处理情况,将其分为前哨淋巴结活组织检查(SLNB)组(2519例)和SLNB联合腋窝淋巴结清扫(ALND)组(1352例)。其中,又将SLNB组患者分为术后放射治疗(PMRT)组(706例)和无术后放射治疗(Non-PMRT)组(1813例)。通过倾向评分匹配法(PSM)平衡基线特征后,采用Kaplan-Meier法及Log-rank检验比较不同组患者的BCSS。单因素分析、多因素分析及亚组分析均采用Cox比例风险回归模型筛选其风险因素。结果:共185例患者死于乳腺癌,其中SLNB组81例,ALND组104例。SLNB组中,Non-PMRT组乳腺癌相关死亡37例,PMRT组35例。生存分析显示:ALND组与SLNB组患者的BCSS比较,差异无统计学意义(χ^(2)=0.260,P=0.610);Non-PMRT组和PMRT组患者的BCSS比较,差异无统计学意义(χ^(2)=0.893,P=0.345)。Cox回归分析结果显示,对于全部患者,年龄、组织学分级、肿瘤大小和分子分型是患者BCSS的独立影响因素;对于SLNB组患者,分子分型是患者BCSS的独立影响因素。ALND并没有显著改善患者的BCSS(HR=0.953,95%CI:0.710~1.279,P=0.750);同时,PMRT也没有显著改善仅行SLNB患者的BCSS(HR=1.193,95%CI:0.746~1.908,P=0.462)。亚组分析结果显示,无论患者是否接受PMRT,ALND均没有为其带来BCSS获益(未接受PMRT:HR=0.998,95%CI=0.700~1.424,P=0.993;接受PMRT:HR=1.286,95%CI=0.770~2.148,P=0.336)。同时,ALND也没有给其他亚组患者带来获益,尤其对于激素受体阴性、HER-2阳性患者,ALND还可能对其BCSS造成不良影响(HR=9.577,95%CI=1.226~74.849,P=0.031)。结论:ALND和PMRT均未能有效改善T_(1-2)N_(1mi)M_(0)期乳腺癌患者的预后。

Objective To investigate the impact of different axillary treatments on the breast cancerspecific survival(BCSS)in Ti-2NmM breast cancer patients afier mastectomy.Methods This was a retrospective cohort study.The clinical data of 3871 patients with unilateral invasive ductal carcinoma of the breast at stage T_(1-2)N_(1mi)M_(0) from 2010 to 2019 in the SEER database were analyzed.According to the postoperative axillary management,all patients were divided into sentinel lymph node biopsy(SLNB)group(2519 cases,receiving only SLNB)and axillary lymph node dissection(ALND)group(1352 cases,receiving SLNB combined with ALND).The patients in SLNB group were subdivided into post-mastectomy radiotherapy(PMRT)group(706 cases)and non-PMRT group(1813 cases)according to whether they received PMRT or not.After balancing the baseline characteristics by propensity score matching(PSM),the Kaplan-Meier and log-rank test were used to compare BCSS of patients between groups.The Cox proportional hazards regression model was used for single-factor analysis,multiple-factor analysis and subgroup analysis.Results A total of 185 patients died of breast cancer,including 81 in the SLNB group and 104 in the ALND group.In the SLNB group,there were 37 breast cancer-related deaths in the non-PMRT group and 35 in the PMRT group.Survival analysis showed that there was no significant difference in BCSS between the ALND group and the SLNB group(χ^(2)=0.260,P=0.610)and between the non-PMRT group and the PMRT group(χ^(2)=0.893,P=0.345).The results of Cox regression analysis showed that for all patients,age,histological grade,tumor size and molecular typing were independent influencing factors for BCSS;for patients in SLNB group,molecular typing was an independent influencing factor for BCSS.ALND did not significantly improve BCSS of all patients(HR=0.953,95%CI:0.710-1.279,P=0.750),and PMRT did not significantly improve BCSS of the patients only receiving SLNB(HR=1.193,95%CI:0.746-1.908,P=0.462).Subgroup analysis showed that whether the patients received radiotherapy or not,there was no benefit of BCSS from ALND(no PMRT:HR=0.998,95%CI:0.700-1.424,P=0.993;PMRT:HR=1.286,95%CI:0.770-2.148,P=0.336).Meanwhile,ALND did not bring benefit to other subgroups of patients;in hormone receptor-negative and HER-2-positive patients,ALND even showed adverse effect on their BCSS(HR=9.577,95%CI:1.226-74.849,P=0.031).Conclusion Both ALND and PMRT bring no significant improvement on the prognosis of T_(1-2)N_(1mi)M_(0) breast cancer.