乳腺浸润性微乳头状癌97 例临床分析

doi:10.3877/cma. j. issn.1674-0807.2015.06.004

目的

探讨乳腺浸润性微乳头状癌(IMPC)患者的临床病理特征及其预后。

方法

回顾性分析解放军总医院2005 年1 月到2015 年5 月收治的97 例乳腺浸润性微乳头状癌患者的临床特点、影像学表现、病理特征及治疗、预后,并分析IMPC 淋巴结转移与临床病理特征的关系。单因素分析采用Pearson χ² 检验,多因素分析采用Logistic 回归模型;采用Kaplan-Meier 及COX 法分析IMPC 患者的预后。

结果

IMPC 患者占同期乳腺癌患者的3% (97/3231);年龄为28 ～89 岁,中位年龄是50 岁;淋巴结转移率为72.2%(70/97),脉管侵犯率为40.2%(39/97);单因素分析显示,组织学分级3 级的患者淋巴结转移率高于组织学分级2 级的患者,差异具有统计学意义(78.9%比47.6%,χ²=8.039,P=0.005)。不同分子分型的IMPC 患者的淋巴结转移率差异具有统计学意义(χ²=8.141,P=0.033);多因素分析证明,组织学分级是淋巴结转移的独立危险因素(OR=0.165,95%CI:0.053 ～0.517,P=0.002);随访结果显示,5 年OS 为92%。 COX 分析结果显示,IMPC 患者年龄、肿瘤直径、组织学分级、pTNM 分期、分子分型、脉管癌栓、淋巴结转移、Ki67 指数等因素均不是影响OS 的高危因素。

结论

IMPC 是一种侵袭性高的乳腺癌,高淋巴结转移率可能与IMPC 的分子分型及组织学分期有关。

关键词: 乳腺肿瘤, 病理学, 临床, 淋巴转移, 预后

Objective

To investigate the clinicopathological features and prognosis of the patients with breast invasive micropapaillary carcinoma (IMPC).

Methods

The clinical, imaging, and pathological findings, treatment and prognosis of 97 IMPC patients treated in General Hospital of PLA from January 2005 to May 2015 were retrospectively analyzed. The relationship between lymph node metastasis and clinicopathological features of IMPC patients. The univariate analysis was performed using Pearson χ² test, multivariate analysis using Logistic regression model. The prognosis of IMPC patients was analyzed by Kaplan-Meier and COX method.

Results

IMPC accounted for 3% of the patients with breast cancer in the same period (97/3231).The median age was 50 years old (28-89 years).The rate of axillary lymph node metastasis was 72.2%(70/97) and the lymphatic invasion rate was 40.2%(39/97). The univariate analysis showed that the rate of lymph node metastasis in the patients with histological grade 3 was significantly higher than that in the patients with histological grade 2(78.9% vs 47.6%,χ²=8.039,P=0.005).and there was a significant difference in lymph node metastasis rate among different molecular types of IMPC(χ² =8.141,P=0.033). Multivariate analysis showed that histological grade was an independent risk factor for lymph node metastasis(OR=0.165,95%CI:0.053-0.517,P=0.002). The follow-up results showed that 5-year overall survival was 92%. COX analysis showed that the patient's age,tumor diameter,histological grade,pTNM stage,molecular type,vascular tumor thrombus, lymph node metastasis and Ki67 index were not the high risk factors of overall survival.

Conclusion

IMPC is a variant of breast carcinoma with high risk of invasion, and the high incidence of lymph node metastasis may be related to the histological stage and instinctive molecular characteristics of tumor.

Key words: Breast neoplasms, Pathology, clinical, Lymphatic metastasis, Prognosis

表1 乳腺浸润性微乳头状癌患者淋巴结转移的影响因素及量化值

变量	量化值
年龄	连续变量
肿瘤直径	＜5 cm=1,≥5 cm=2
ER	阴性=0,阳性=1
PR	阴性=0,阳性=1
HER-2	阴性=0,阳性=1
Ki67	连续变量
脉管癌栓	无=0,有=1
组织学分级	1级=1,2级=2,3级=3
分子分型	luminal A型=1,luminal B型=2,HER-2过表达型=3,三阴性=4
腋窝淋巴结转移	无转移=0,转移=1

表1 乳腺浸润性微乳头状癌患者淋巴结转移的影响因素及量化值

变量	量化值
年龄	连续变量
肿瘤直径	＜5 cm=1,≥5 cm=2
ER	阴性=0,阳性=1
PR	阴性=0,阳性=1
HER-2	阴性=0,阳性=1
Ki67	连续变量
脉管癌栓	无=0,有=1
组织学分级	1级=1,2级=2,3级=3
分子分型	luminal A型=1,luminal B型=2,HER-2过表达型=3,三阴性=4
腋窝淋巴结转移	无转移=0,转移=1

表2 97 例乳腺浸润性微乳头状癌患者的临床病理特征

临床病理特征	例数(%)
超声表现
结节	95(97.9)
边界不清	90(92.8)
伴同侧腋窝淋巴结肿大	37(38.1)
CDFI可见血流信号	88(90.7)
BI-RADS Ⅳ-US	10(10.3)
BI-RADS Ⅴ-US	87(89.7)
组织学分级
1	0(0.0)
2	21(21.6)
3	76(78.4)
ER
阳性	75(77.3)
阴性	22(22.7)
PR
阳性	69(71.1)
阴性	28(29.9)
HER-2
阳性	26(26.8)
阴性	71(73.2)
Ki67^a
＜20%	27(27.8)
≥20%	70(72.1)
淋巴结转移
0	27(27.8)
1～3	16(16.5)
≥4	54(55.7)
pTNM
Ⅰ	12(12.4)
Ⅱ	36(37.1)
Ⅲ	49(50.5)
脉管受累
是	39(40.2)
否	58(59.8)
分子分型
luminal A	13(13.4)
luminal B	67(69.1)
HER-2过表达型	9(9.3)
三阴性	8(8.2)
手术方式
乳腺癌改良根治术	87(89.7)
乳腺单纯切除+前哨淋巴结活组织检查	4(4.1)
保留乳房手术	3(3.1)
保留乳房+术中放射治疗	2(2.1)
保留皮肤、乳头乳晕复合体皮下腺体切除术	1(1.0)
辅助治疗^b
辅助化疗	65(67.0)
辅助放疗	61(61.9)
辅助内分泌治疗	76(78.4)
分子靶向治疗	21(21.6)

表2 97 例乳腺浸润性微乳头状癌患者的临床病理特征

临床病理特征	例数(%)
超声表现
结节	95(97.9)
边界不清	90(92.8)
伴同侧腋窝淋巴结肿大	37(38.1)
CDFI可见血流信号	88(90.7)
BI-RADS Ⅳ-US	10(10.3)
BI-RADS Ⅴ-US	87(89.7)
组织学分级
1	0(0.0)
2	21(21.6)
3	76(78.4)
ER
阳性	75(77.3)
阴性	22(22.7)
PR
阳性	69(71.1)
阴性	28(29.9)
HER-2
阳性	26(26.8)
阴性	71(73.2)
Ki67^a
＜20%	27(27.8)
≥20%	70(72.1)
淋巴结转移
0	27(27.8)
1～3	16(16.5)
≥4	54(55.7)
pTNM
Ⅰ	12(12.4)
Ⅱ	36(37.1)
Ⅲ	49(50.5)
脉管受累
是	39(40.2)
否	58(59.8)
分子分型
luminal A	13(13.4)
luminal B	67(69.1)
HER-2过表达型	9(9.3)
三阴性	8(8.2)
手术方式
乳腺癌改良根治术	87(89.7)
乳腺单纯切除+前哨淋巴结活组织检查	4(4.1)
保留乳房手术	3(3.1)
保留乳房+术中放射治疗	2(2.1)
保留皮肤、乳头乳晕复合体皮下腺体切除术	1(1.0)
辅助治疗^b
辅助化疗	65(67.0)
辅助放疗	61(61.9)
辅助内分泌治疗	76(78.4)
分子靶向治疗	21(21.6)

表3 乳腺浸润性微乳头状癌患者的组织学分级与淋巴结转移的关系[例(%)]

组织学分级	例数	淋巴结转移		χ²值	P值
组织学分级	例数	阳性	阴性	χ²值	P值
1+2	21	10(47.6)	11(52.4)	8.039		0.005
3	76	60(78.9)	16(21.1)

表3 乳腺浸润性微乳头状癌患者的组织学分级与淋巴结转移的关系[例(%)]

组织学分级	例数	淋巴结转移		χ²值	P值
组织学分级	例数	阳性	阴性	χ²值	P值
1+2	21	10(47.6)	11(52.4)	8.039		0.005
3	76	60(78.9)	16(21.1)

表4 乳腺浸润性微乳头状癌分子分型与淋巴结转移的关系[例(%)]

分子分型	例数	淋巴结转移		χ²值	P值
分子分型	例数	阳性	阴性	χ²值	P值
luminal A型	13	8(61.5)	5(38.5)	8.141	0.033
luminal B型	67	45(67.2)	22(32.8)	8.141	0.033
HER-2过表达型	9	9(100)	0(0)
三阴性	8	8(100)	0(0)

表4 乳腺浸润性微乳头状癌分子分型与淋巴结转移的关系[例(%)]

分子分型	例数	淋巴结转移		χ²值	P值
分子分型	例数	阳性	阴性	χ²值	P值
luminal A型	13	8(61.5)	5(38.5)	8.141	0.033
luminal B型	67	45(67.2)	22(32.8)	8.141	0.033
HER-2过表达型	9	9(100)	0(0)
三阴性	8	8(100)	0(0)

表5 乳腺浸润性微乳头状癌患者淋巴结转移的Logistic 回归分析

变量	B值	标准误	Wald值	P值	OR值	95%CI
年龄	-0.014	0.021	0.428	0.513	0.986	0.947～1.028
肿瘤直径	-0.472	0.694	0.464	0.496	0.623	0.160～2.430
ER	0.679	1.308	0.270	0.603	1.973	0.152～25.596
PR	0.657	0.919	0.511	0.475	1.929	0.318～11.687
HER-2	-0.044	0.534	0.007	0.934	0.957	0.336～2.723
Ki67	-0.015	0.013	1.366	0.243	0.985	0.962～1.010
脉管癌栓	0.167	0.513	0.107	0.744	1.182	0.433～3.228
组织学分级	-1.801	0.583	9.550	0.002	0.165	0.053～0.517
分子分型	-	-	2.938	0.401	-	-

表5 乳腺浸润性微乳头状癌患者淋巴结转移的Logistic 回归分析

变量	B值	标准误	Wald值	P值	OR值	95%CI
年龄	-0.014	0.021	0.428	0.513	0.986	0.947～1.028
肿瘤直径	-0.472	0.694	0.464	0.496	0.623	0.160～2.430
ER	0.679	1.308	0.270	0.603	1.973	0.152～25.596
PR	0.657	0.919	0.511	0.475	1.929	0.318～11.687
HER-2	-0.044	0.534	0.007	0.934	0.957	0.336～2.723
Ki67	-0.015	0.013	1.366	0.243	0.985	0.962～1.010
脉管癌栓	0.167	0.513	0.107	0.744	1.182	0.433～3.228
组织学分级	-1.801	0.583	9.550	0.002	0.165	0.053～0.517
分子分型	-	-	2.938	0.401	-	-

图1 97 例乳腺浸润性乳头状癌患者的总生存曲线

图2 97 例乳腺浸润性乳头状癌患者的淋巴结转移与总生存率的关系注:两组比较,χ²=1.366,P=0.242

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Clinical analysis of invasive micropapillary carcinoma of the breast: 97 cases

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Clinical analysis of invasive micropapillary carcinoma of the breast: 97 cases