I~III期三阴性乳腺癌病人接受保乳手术或乳房切除术的预后分析

doi:10.16139/j.1007-9610.2023.04.014

摘要/Abstract

摘要：

目的：探讨Ⅰ~Ⅲ期三阴性乳腺癌（triple-negative breast cancer, TNBC）病人接受保乳手术（breast-conserving surgery, BCS）或乳房切除术(mastectomy, M)对病人无病生存（disease free survival, DFS）和总生存（overall survival, OS）的影响。方法：收集2009年1月至2018年12月上海交通大学医学院附属瑞金医院乳腺疾病诊治中心收治的844例可手术Ⅰ~Ⅲ期TNBC病人，根据手术方式分为BCS组和M组。采用COX回归分析评估病人的临床特征和手术方式对病人DFS和OS的影响。进一步应用倾向性评分匹配平衡两组病人间存在的基线特征差异，评估两组手术的预后差异。结果：533例（63.15%）接受M，311例（36.85%）接受BCS。与M组相比，年轻、肿瘤小、淋巴结阴性、HER2表达缺失（HER2-0）的病人更多接受BCS。中位随访时间72个月。多因素分析表明，M组病人的OS率低于BCS组病人（HR=2.02，95% CI: 1.04~3.91，P=0.038），但两组DFS差异无统计学意义（HR=1.42，95% CI: 0.94~2.15, P=0.100）。将病人T分期、N分期（pN）和年龄等因素进行倾向性评分匹配平衡后，BCS组和M组病人OS率（P=0.114）和DFS率（P=0.124）差异无统计学意义。结论：在Ⅰ~Ⅲ期TNBC病人中，年轻、肿瘤小、淋巴结阴性和HER2-0病人更多选择BCS。匹配相关临床病理指标后，TNBC病人接受BCS或M手术方式的预后差异无统计学意义。

关键词: 乳腺癌, 三阴性, 保乳手术, 乳房切除术

Abstract:

Objective: To investigate the effect of breast-conserving surgery (BCS) or mastectomy (M) in patients with stage Ⅰ-Ⅲ triple-negative breast cancer (TNBC) on disease free survival (DFS) and overall survival (OS). Methods: A total of 844 patients with stage Ⅰ-Ⅲ TNBC who were admitted to Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine from January 2009 to December 2018 were collected and divided into BCS and M groups according to the surgical method. COX regression analysis was used to evaluate the influence of clinical characteristics and surgical methods on DFS and OS of the patients. The propensity score was further used to balance the differences in baseline characteristics between the two groups of patients, and to evaluate the differences in the prognosis of two groups of patients. Results: There were 533 patients (63.15%) underwent M and 311 patients (36.85%) underwent BCS. Patients with younger age, smaller tumor size, negative lymph node, and loss of HER2 expression (HER2-0) were more tend to BCS group compared to M group. Median follow-up time was 72 months. Multivariate COX analysis showed that the OS of M group was lower than that of BCS group (HR=2.02, 95% CI: 1.04-3.91, P=0.038), but there was no significant difference in DFS between the two groups (HR=1.42, 95% CI: 0.94-2.15, P=0.100). After propensity score matching for factors such as T stage, N stage and age, the results showed that there was no significant difference in OS (P=0.114) and DFS (P=0.124) between BCS and M groups. Conclusions: Among patients with stage Ⅰ-Ⅲ TNBC, patients with younger age, smaller tumor, negative lymph node, and HER2-0 were more likely to choose BCS. After propensity score matching for relevant clinicopathological parameters, the results indicated that there was no significant difference in OS and DFS of the TNBC patients undergoing BCS or M surgery.

Key words: Breast cancer, Triple-negative, Breast-conserving surgery, Mastectomy

中图分类号:

R737.9

朱巧俐, 苗伊鸣, 陈小松. I~III期三阴性乳腺癌病人接受保乳手术或乳房切除术的预后分析[J]. 外科理论与实践, 2023, 28(04): 371-377.

ZHU Qiaoli, MIAO Yiming, CHEN Xiaosong. Prognostic analysis of breast-conserving surgery or mastectomy in patients with stage Ⅰ-Ⅲ triple-negative breast cancer[J]. Journal of Surgery Concepts & Practice, 2023, 28(04): 371-377.

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Factors	BCS（n=311）	M（n=533）	F/x² value	P value
Age(years)	53.68±13.05	57.23±11.85	16.3	<0.001
BMI(kg/m²)	23.10±3.01	23.01±2.79	0.2	0.671
Menopause status[n(%)]
Pre-menopause	128 (41.16)	167 (31.33)	8.3	0.004
Post-menopause	183 (58.84)	366 (68.67)
pT[n(%)]
T₁	192 (61.74)	226 (42.40)	29.4	<0.001
T_2-3	119 (38.26)	307 (57.60)
pN[n(%)]
Negative	250 (80.39)	358 (67.17)	17.0	<0.001
Positive	61 (19.61)	175 (32.83)
HER2[n(%)]
HER2-0	135 (43.41)	182 (34.15)	7.2	0.007
HER2 low	176 (56.59)	351 (65.85)
Ki-67[n(%)]
≤14%	42 (13.50)	90 (16.89)	1.7	0.192
>14%	269 (86.50)	443 (83.11)
Pathologic typing[n(%)]
DCIS	5 (1.61)	11 (2.07)
IDC	290 (93.25)	490 (91.93)	0.5	0.776
Others[n(%)]	16 (5.14)	32 (6.00)
Grading
Ⅰ-Ⅱ	59 (18.97)	129 (24.20)
Ⅲ	200 (64.31)	322 (60.41)	3.1	0.211
Unknown	52 (16.72)	82 (15.39)
Chemotherapy[n(%)]
No	41 (13.18)	63 (11.82)	0.3	0.561
Yes	270 (86.82)	470 (88.18)

Factors	OR	95%CI	P value
Age（years） ≥60 vs. <60	1.02	1.01-1.04	0.013
Menopause status post-menopause vs. pre-menopause	0.99	0.63-1.57	0.967
pT T_2-3 vs. T₁	2.17	1.61-2.91	<0.001
pN N positive vs. N negative	1.84	1.30-2.59	<0.001
HER2 HER2 low vs. HER2-0	1.42	1.05-1.92	0.023

Factors	OS	DFS
Factors	P value	P value
Age（years） ≥60 vs. <60	0.07	0.158
Menopause status post-menopause vs. pre-menopause	0.09	0.061
BMI(kg/m²)	0.773	0.605
≥24 vs. ≥18.5，<24	0.473	0.698
<18.5 vs. ≥18.5，<24	0.967	0.375
Pathologic typing	0.589	0.507
IDC vs. DCIS	0.78	0.725
Others vs. DCIS	0.723	0.333
pT T_2-3 vs. T₁	0.001	<0.001
pN N positive vs. N negative	<0.001	<0.001
Grading	0.291	0.733
Ⅲ vs. Ⅰ-Ⅱ	0.981	0.566
Unknown vs. Ⅰ-Ⅱ	0.156	0.897
HER2 HER2 low vs. HER2-0	0.362	0.749
Ki-67 >14% vs. ≤14%	0.119	0.045
Chemotherapy Yes vs. No	0.112	0.049
Surgical approach M vs. BCS	0.002	0.005

Factors	OS			DFS
Factors	HR	95% CI	P value	HR	95%CI	P value
Age（years） ≥60 vs. <60	1.37	0.64-2.91	0.419	/	/	/
Menopause status Post-menopause vs. pre-menopause	1.23	0.53-2.84	0.626	1.33	0.9-1.97	0.155
Surgical approach M vs. BCS	2.02	1.04-3.91	0.038	1.42	0.94-2.15	0.100
pT T_2-3 vs. T₁	2.02	1.17-3.48	0.011	1.82	1.25-2.65	0.002
Chemotherapy Yes vs. No	/	/	/	0.58	0.35-0.94	0.026
pN N Positive vs. N Negative	3.22	1.96-5.30	<0.001	2.12	1.48-3.05	0.001
Ki-67 >14% vs. ≤14%	/	/	/	0.67	0.44-1.04	0.076

Factors	BCS （n=257）	M （n=257）	F/x² value	P value
Age(years)	54.79±12.76)	56.02±11.67)	1.3	0.253
BMI(kg/m²)	23.11±3.00)	23.14±2.82)	0.0	0.912
Menopause status[n(%)]
Pre-menopause	100 (38.91)	87 (33.85)	1.4	0.233
Post-menopause	157 (61.09)	170 (66.15)
pT[n(%)]
T₁	148 (57.59)	145 (56.42)	0.7	0.789
T_2-3	109 (42.41)	112 (43.58)
pN[n(%)]
Negative	202 (78.60)	208 (80.93)	0.4	0.51
Positive	55 (21.40)	49 (19.07)
HER2[n(%)]
HER2 0	103 (40.08)	107 (41.63)	0.1	0.72
HER2 low	154 (59.92)	150 (58.37)
Ki-67[n(%)]
≤14%	34 (13.23)	42 (16.34)	1.0	0.32
>14%	223 (86.77)	215 (83.66)
Pathologic typing[n(%)]
DCIS	5 (1.95)	6 (2.34)	0.3	0.854
IDC	242 (94.16)	243 (94.55)
Others	10 (3.89)	8 (3.11)
Grading[n(%)]
Ⅰ-Ⅱ	52 (20.23)	47 (18.29)	1.3	0.528
Ⅲ	168 (65.37)	164 (63.81)
Unknown	37 (14.40)	46 (17.90)
Chemotherapy[n(%)]
No	30 (11.67)	39 (15.18)	1.4	0.244
Yes	227 (88.33%)	218 (84.82%)