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中华乳腺病杂志(电子版)

中华乳腺病杂志(电子版) ›› 2019, Vol. 13 ›› Issue (02) : 87 -92. doi: 10.3877/cma.j.issn.1674-0807.2019.02.005

所属专题： 文献；

论著

乳腺癌伴同时型同侧锁骨上淋巴结转移患者新辅助化疗后锁骨上淋巴结阳性的危险因素及预后分析
马丹丹1, 齐晓伟1, 张毅1, 姜军1,†()   
  1. 1. 400038　重庆，陆军军医大学西南医院乳腺甲状腺外科
  • 收稿日期:2019-02-26 出版日期:2019-04-01
  • 通信作者: 姜军

Risk factors of supraclavicular lymph node positive after neoadjuvant chemotherapy and prognostic analysis in breast cancer patients with synchronous ipsilateral supraclavicular lymph node metastasis

Dandan Ma1, Xiaowei Qi1, Yi Zhang1, Jun Jiang1,†()   

  1. 1. Department of Breast and Thyroid Surgery, Southwest Hospital, Army Medical University, Chongqing 400038, China
  • Received:2019-02-26 Published:2019-04-01
  • Corresponding author: Jun Jiang
  • About author:
    Corresponding author: Jiang Jun, Email:
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引用本文：

马丹丹, 齐晓伟, 张毅, 姜军. 乳腺癌伴同时型同侧锁骨上淋巴结转移患者新辅助化疗后锁骨上淋巴结阳性的危险因素及预后分析[J]. 中华乳腺病杂志(电子版), 2019, 13(02): 87-92.

Dandan Ma, Xiaowei Qi, Yi Zhang, Jun Jiang. Risk factors of supraclavicular lymph node positive after neoadjuvant chemotherapy and prognostic analysis in breast cancer patients with synchronous ipsilateral supraclavicular lymph node metastasis[J]. Chinese Journal of Breast Disease(Electronic Edition), 2019, 13(02): 87-92.

目的

探讨乳腺癌伴同时型同侧锁骨上淋巴结转移(ISLNM)患者新辅助化疗后锁骨上淋巴结仍为阳性的危险因素，并对患者的生存情况进行分析。

方法

收集2005年1月至2015年7月在陆军军医大学西南医院乳腺甲状腺外科就诊的乳腺癌且影像学提示存在同时型ISLNM的患者资料进行回顾性研究。共纳入患者96例，均完成4～6个周期新辅助化疗、放射治疗及乳腺癌改良根治手术联合同侧锁骨上淋巴结清扫术，ER、PR或HER-2阳性患者分别接受了内分泌或靶向治疗。采用χ2检验及Fisher确切概率法分析患者的临床病理特征与新辅助化疗后锁骨上淋巴结阳性的关系，应用Logistic回归分析新辅助化疗后锁骨上淋巴结阳性的危险因素。采用Kaplan-Meier生存曲线分析患者的OS和DFS。

结果

术后病理显示：96例患者中，锁骨上淋巴结阳性50例，占总数的52.1%。单因素分析结果显示，新辅助化疗后同时型同侧锁骨上淋巴结阳性组与阴性组比较，以下临床病理特征的差异有统计学意义：腋窝淋巴结阳性数目、锁骨下淋巴结状态、内乳淋巴结状态及Ki67 (χ2＝36.501、20.548、6.750、5.186，P均<0.050)。多因素分析结果显示：新辅助化疗后腋窝淋巴结阳性数目≥4枚是同时型同侧锁骨上淋巴结阳性患者的独立危险因素(腋窝淋巴结阳性数目为4～9枚：OR＝10.234, 95%CI：1.978～52.946, P＝0.006；腋窝淋巴结阳性数目>9枚：OR＝22.322, 95%CI：4.887～101.963，P<0.001)。96例患者的3年DFS和OS分别为64.7%、75.8%；5年DFS和OS分别为49.6%、65.0%。

结论

新辅助化疗后腋窝淋巴结阳性数目≥4枚是乳腺癌患者新辅助化疗后同时型同侧锁骨上淋巴结阳性的高危因素。对于影像学提示同时型ISLNM的乳腺癌患者，建议进行局部治疗(乳房、腋窝和锁骨上区手术及放射治疗)联合全身治疗(化疗、必要的内分泌及靶向治疗)，以改善其生存。

关键词: 化学疗法，辅助, 乳腺肿瘤, 淋巴结清扫, 危险因素, 生存预后
Objective

To explore the risk factors of supraclavicular lymph node positive after neoadjuvant chemotherapy in breast cancer patients with synchronous ipsilateral supraclavicular lymph node metastasis, and analyze the prognosis of those patients.

Methods

A total of 96 breast cancer patients in the Department of Breast and Thyroid Surgery, Southwest Hospital, Army Medical University from January 2005 to July 2015 were enrolled in this retrospective study. The imaging findings indicated synchronous ipsilateral supraclavicular lymph node metastasis in all patients. All patients were treated with preoperative neoadjuvant chemotherapy of 4-6 cycles, radiotherapy, modified radical mastectomy and ipsilateral supraclavicular lymph node dissection. Moreover, the patients with ER, PR or HER-2 positive received the endocrine therapy and targeted therapy, respectively. χ2 test and Fisher exact probability test were used to analyze the relationship between clinicopathological characteristics and positive ipsilateral supraclavicular lymph nodes after neoadjuvant chemotherapy. Logistic regression was used to analyze the risk factors of positive ipsilateral supraclavicular lymph nodes after neoadjuvant chemotherapy. Kaplan-Meier survival curve was drawn to analyze the OS and DFS of all patients.

Results

Postoperative pathology showed that among the 96 patients, 50 cases had positive supraclavicular lymph nodes, accounting for 53% of the total. Univariate analysis showed that the following clinicopathological characteristics were significantly different between ipsilateral supraclavicular lymph node-positive group and ipsilateral supraclavicular lymph node-negative group after neoadjuvant chemotherapy: number of positive axillary lymph nodes, supraclavicular lymph nodes, internal mammary lymph nodes and Ki67 (χ2=36.501, 20.548, 6.750, 5.186, all P<0.050). Multivariate analysis showed that the number of positive axillary lymph nodes≥4 was an independent risk factor for synchronous ipsilateral supraclavicular lymph node metastasis (4-9 nodes: OR=10.234, 95%CI: 1.978-52.946, P=0.006; >9 nodes: OR=22.322, 95%CI: 4.887-101.963, P<0.001). The 3-year DFS and OS of 96 patients were 64.7% and 75.8%, respectively; the 5-year DFS and OS were 49.6% and 65.0%, respectively.

Conclusions

The number of positive axillary lymph nodes after neoadjuvant chemotherapy≥4 is a high risk factor for synchronous ipsilateral supraclavicular lymph node metastasis in breast cancer patients. If the imaging evidences suggest synchronous ipsilateral supraclavicular lymph node metastasis, local treatment (breast, axillary and supraclavicular surgery+ radiation therapy) combined with systemic therapy (chemotherapy+ endocrine/targeted therapy if necessary) are recommended in order to improve the survival of patients.

Key words: Chemotherapy, adjuvant, Breast neoplasms, Lymph node excision, Prognosis, Risk factors
表1 影响新辅助化疗后锁骨上淋巴结状态的临床病理因素的赋值表
临床病理因素 变量 分类赋值
年龄 X <35岁＝1，≥35岁且<45岁＝2，≥45岁＝3
月经状态 X 绝经＝0，未绝经＝1
术前肿瘤大小 X <2 cm＝1，≥2 cm且<5 cm＝2, ≥5 cm＝3
ER状态 X 阴性＝0，阳性＝1
PR状态 X 阴性＝0，阳性＝1
HER-2状态 X 阴性＝0，阳性＝1
Ki67 X ≤20%＝1，>20%＝2
腋窝淋巴结阳性数 X 0枚＝0，1～3枚＝1，4～9枚＝2，>9枚＝3
胸肌间淋巴结状态 X 阴性＝0，阳性＝1
锁骨下淋巴结状态 X 阴性＝0，阳性＝1
内乳淋巴结状态 X 阴性＝0，阳性＝1
锁骨上淋巴结状态 Y 阴性＝0，阳性＝1
表2 96例乳腺癌伴同时型锁骨上淋巴结转移患者的临床病理特征与新辅助化疗后锁骨上淋巴结阳性的关系
临床病理特征 锁骨上淋巴结(例) χ2值 P值
阳性(n＝50) 阴性(n＝46)
年龄a ? ? 3.343 0.188
? 　<35岁 8 5 ? ?
? 　≥35岁且<45岁 12 19 ? ?
? 　≥45岁 30 22 ? ?
月经状态 ? ? 1.383 0.240
? 　绝经前 29 32 ? ?
? 　绝经后 21 14 ? ?
术前肿瘤大小b ? ? 2.095 0.351
? 　<2 cm 8 5 ? ?
? 　≥2 cm且<5 cm 30 34 ? ?
? 　≥5 cm 12 7 ? ?
ER ? ? 0.386 0.534
? 　阳性 26 21 ? ?
? 　阴性 24 25 ? ?
PR ? ? 2.451 0.117
? 　阳性 23 14 ? ?
? 　阴性 27 32 ? ?
HER-2 ? ? 0.533 0.466
? 　阳性 16 18 ? ?
? 　阴性 34 28 ? ?
腋窝淋巴结阳性 ? ? 36.501 <0.001
? 　0枚 3 17 ? ?
? 　1～3枚 5 18 ? ?
? 　4～9枚 10 5 ? ?
? 　>9枚 32 6 ? ?
锁骨下淋巴结c ? ? 20.548 <0.001
? 　阳性 21 5 ? ?
? 　阴性 3 18 ? ?
内乳淋巴结c ? ? 6.750 0.009
? 　阳性 10 2 ? ?
? 　阴性 5 10 ? ?
胸肌间淋巴结c ? ? ? 0.116d
? 　阳性 12 5 ? ?
? 　阴性 1 4 ? ?
Ki67 ? ? 5.186 0.023
? 　≤20% 29 16 ? ?
? 　>20% 21 30 ? ?
表3 96例乳腺癌伴同时型同侧锁骨上淋巴结转移患者新辅助化疗后锁骨上淋巴结阳性的危险因素
临床病理特征 回归系数 标准误 Wald值 P值 OR值 95%置信区间
腋窝淋巴结阳性 ? ? ? ? ? ?
? 　0 参考值 ? ? ? ? ?
? 　1～3枚 0.575 0.882 0.424 0.660 1.430 0.291～7.017　
? 　4～9枚 3.121 1.010 9.545 0.006 10.234 1.978～52.946　
? 　>9枚 3.360 0.887 14.334 <0.001 22.322 4.887～101.963
图1 96例乳腺癌伴同时型同侧锁骨上淋巴结转移患者的总生存曲线
图2 96例乳腺癌伴同时型同侧锁骨上淋巴结转移患者的无瘤生存曲线
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