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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 (06) : 336 -342. doi: 10.3877/cma.j.issn.1674-0807.2019.06.004

所属专题： 文献；

论著

46例乳腺巨大恶性肿瘤切除术后经皮瓣修复缺损者的预后分析
饶南燕1,†(), 杨雅平1, 陈凯1, 李顺荣1, 朱李玲1, 吴畏1, 苏逢锡1, 刘强1   
  1. 1. 510120　广州，中山大学孙逸仙纪念医院乳腺肿瘤整形外科
  • 收稿日期:2018-10-10 出版日期:2019-12-01
  • 通信作者: 饶南燕

Prognostic analysis of 46 patients receiving resection of gaint breast tumor and defect repair by autologous tissue flap

Nanyan Rao1,†(), Yaping Yang1, Kai Chen1, Shunrong Li1, Liling Zhu1, Wei Wu1, Fengxi Su1, Qiang Liu1   

  1. 1. Department of Breast Oncoplastic Surgery, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou 510120, China
  • Received:2018-10-10 Published:2019-12-01
  • Corresponding author: Nanyan Rao
  • About author:
    Corresponding author: Rao Nanyan, Email:
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饶南燕, 杨雅平, 陈凯, 李顺荣, 朱李玲, 吴畏, 苏逢锡, 刘强. 46例乳腺巨大恶性肿瘤切除术后经皮瓣修复缺损者的预后分析[J]. 中华乳腺病杂志(电子版), 2019, 13(06): 336-342.

Nanyan Rao, Yaping Yang, Kai Chen, Shunrong Li, Liling Zhu, Wei Wu, Fengxi Su, Qiang Liu. Prognostic analysis of 46 patients receiving resection of gaint breast tumor and defect repair by autologous tissue flap[J]. Chinese Journal of Breast Disease(Electronic Edition), 2019, 13(06): 336-342.

目的

分析经自体皮瓣修复乳腺巨大恶性肿瘤术后缺损者的预后及相关因素。

方法

回顾性分析2012年4月至2018年5月中山大学孙逸仙纪念医院收治的46例乳腺巨大恶性肿瘤患者的临床资料。患者接受局部切除术后行自体皮瓣修复缺损。根据不同病理类型、是否伴有远处转移、切缘能否达到阴性以及治疗反应性进行亚组分析，采用Log-rank检验分析不同亚组的疾病无进展生存(PFS)和OS情况；采用单因素和多因素Cox比例风险回归模型分析PFS和OS的影响因素。

结果

46例患者中，乳腺间叶恶性肿瘤患者7例，其余39例为乳腺癌患者(luminal B型18例，HER-2阳性乳腺癌11例，三阴性乳腺癌10例)。单因素分析发现：(1)乳腺间叶恶性肿瘤患者中位PFS和OS分别为28.5个月(18.1～38.7个月)和28.5个月(18.1～38.9个月), luminal B型乳腺癌患者中位PFS和OS分别为17.2个月(14.1～20.3个月)和25.1个月(13.7～36.6个月)，HER-2阳性乳腺癌患者中位PFS和OS分别为15.6个月(12.9～51.2个月)和35.8个月(19.8～71.8个月)，三阴性乳腺癌患者中位PFS和OS分别为8.6个月(4.6～12.5个月)和18.5个月(5.8～43.5个月)。4种恶性肿瘤相比，患者中位PFS和OS的差异均有统计学意义(PFS：χ2＝16.645，P＝0.001；OS：χ2＝8.617，P＝0.035)。(2)仅有T4局部病灶者(25例)与T4病灶伴远处转移者(21例)相比，中位PFS和OS的差异均无统计学意义[PFS：17.2个月(7.3～27.0个月)比9.8个月(8.6～11.1个月)，χ2＝ 1.369，P＝0.242；OS：28.5个月(14.1～42.9个月)比20.2个月(14.4～25.9个月), χ2＝1.779，P＝0.182]。(3)皮肤切缘阴性者(35例)中位PFS和OS分别为22.1个月(10.8～33.4个月)和22.2个月(11.3～33.2个月)，明显优于皮肤切缘阳性者(11例)的5.1个月(3.0～7.2个月)和10.2个月(5.4～15.0个月)(PFS：χ2＝17.794，P<0.001；OS：χ2＝6.192，P＝0.013)。(4)系统治疗反应好的乳腺癌患者，其中位PFS和OS明显优于治疗反应差的患者[PFS：23.1个月(5.9～40.4个月)比8.7个月(7.8～9.8个月)，χ2＝ 9.868，P＝0.001; OS：46.7个月(25.5～68.0个月)比14.3个月(9.9～18.9个月)，χ2＝8.994，P＝0.002]。将以上因素纳入多因素Cox比例风险回归模型分析后发现，这些因素都不是影响患者PFS和OS的独立预后因素。

结论

乳房巨大恶性肿瘤患者的预后与肿瘤病理类型、切缘是否阴性、全身系统治疗的反应性等多个因素相关，并非由单一因素所决定。

关键词: 乳腺肿瘤, 修复外科手术, 外科皮瓣, 胸壁
Objective

To analyze the prognosis and related factors of patients with giant breast tumors, whose chest wall defects was repaired by autologous tissue flaps after tumor resction.

Methods

The clinical data of 46 giant breast tumor patients in Sun Yat-sen Memorial Hospital of Sun Yat-sen University from April 2012 to May 2018 were retrospectively analyzed. They all underwent the resection of gaint breast tumor and defect repair by autologous tissue flap. Then the subgroup analysis was performed according to different pathological types, distant metastasis status, therapeutic responses and negative margin. Log-rank test was used to analyze the progression-free survival (PFS) and OS of different subgroups. Univariate and multivariate Cox proportional hazard regression models were used to analyze the related factors of PFS and OS.

Results

Among the 46 patients, 7 patients had malignant mesenchymal tumors of the breast, and the other 39 patients had breast cancer (18 luminal B, 11 HER-2 positive, and 10 triple negative). Univariate analysis showed that: (1) the median PFS and OS were 28.5 months (18.1-38.7 months) and 28.5 months (18.1-38.9 months) in patients with malignant mesenchymal tumors, 17.2 months (14.1-20.3 months) and 25.1 months (13.7-36.6 months) in luminal B breast cancer, 15.6 months(12.9- 51.2 months)and 35.8 months(19.8-71.8 months)in HER-2 positive breast cancer, 8.6 months (4.6-12.5 months) and 18.5 months (5.8-43.5 months) in triple negative breast cancer. There were significant differences in median PFS and OS among the four types of malignant tumors (PFS: χ2=16.645, P=0.001; OS: χ2=8.617, P=0.035). (2) The patients with T4 lesions alone (n=25) presented no significant differences in median PFS and OS compared with the patients with T4 lesions and distant metastases (n=21) [PFS: 17.2 months (7.3-27.0 months) vs 9.8 months (8.6-11.1 months), χ2=1.369, P=0.242; OS: 28.5 months (14.1-42.9 months) vs 20.2 months (14.4-25.9 months), χ2=1.779, P=0.182]. (3) The median PFS and OS in patients with negative margin (n=35) were 22.1 months (10.8-33.4 months) and 22.2 months (11.3-33.2 months), respectively, significantly better than those in patients with positive margins(n=11)[5.1 months (3.0-7.2 months) and 10.2 months (5.4-15.0 months)] (PFS: χ2=17.794, P< 0.001; OS: χ2=6.192, P=0.013). (4) The median PFS and OS in patients with good response to systemic treatment were significantly higher than those in patients with poor response [PFS: 23.1 months (5.9-40.4 months) vs 8.7 months (7.8-9.8 months), χ2=9.868, P= 0.001; OS: 46.7 months (25.5-68.0 months) to 14.3 months (9.9-18.9 months), χ2=8.994, P=0.002]. The above-mentioned factors were included in the multivariate Cox proportional hazards regression model and the result showed that these factors were not independent prognostic factors affecting the PFS and OS of breast cancer patients.

Conclusion

The prognosis of the patients with giant malignant breast tumors is related to pathological types of tumors, negative margin and the response to systemic treatment, but none is an independent prognostic factor.

Key words: Breast neoplasms, Reconstructive surgical procedures, Surgical flap, Thoracic wall
图1 乳腺巨大恶性肿瘤患者行皮瓣修复术后效果　a、b图分别所示患者手术前后乳房外观
表1 乳腺巨大恶性肿瘤患者预后影响因素的Cox比例风险回归模型变量赋值表
变量 变量名 分类与赋值
临床分期 X1 T4任何NM0＝0，T4任何NM1＝1
肿瘤病理类型 X2 三阴性乳腺癌＝0，HER-2阳性乳腺癌＝1，luminal B型乳腺癌＝2，乳腺间叶恶性肿瘤＝3
切缘状况 X3 阴性＝0，阳性＝1
系统治疗反应性 X4 好＝0，差＝1
无进展生存 Y 截尾＝0，进展＝1
总生存 Y 截尾＝0，死亡＝1
图2 46例乳腺巨大恶性肿瘤切除术后经皮瓣修复缺损患者的生存曲线
图3 乳腺巨大恶性肿瘤患者肿瘤病理类型与预后的关系
图4 乳腺巨大恶性肿瘤患者肿瘤分期与预后的关系
图5 乳腺巨大恶性肿瘤患者皮肤切缘状态与预后的关系
图6 乳腺巨大恶性肿瘤(乳腺癌)患者系统治疗反应性与预后的关系
表2 经皮瓣修复乳腺巨大恶性肿瘤术后缺损患者无进展生存的单因素与多因素分析
因素 例数 单因素分析 多因素分析
HR值(95%CI) P值 HR值(95%CI) P值
临床分期 ? ? ? ? ?
? T4任何NM0 25 1.00 ? － ?
? T4任何NM1 21 1.66(0.70～3.93) 0.248 － －
肿瘤病理类型 ? ? ? ? ?
? 三阴性乳腺癌 10 1.00 ? 1.00 ?
? HER-2阳性乳腺癌 11 0.14(0.04～0.56) 0.005 0.47(0.10～2.28) 0.345
? luminal B乳腺癌 18 0.17(0.05～0.56) 0.004 0.31(0.07～1.38) 0.125
? 乳腺间叶恶性肿瘤 7 0.07(0.01～0.43) 0.004 － －
切缘状况 ? ? ? ? ?
? 阴性 35 1.00 ? 1.00 ?
? 阳性 11 2.37(1.51～3.72) <0.001 4.27(0.87～20.84) 0.073
系统治疗反应性a ? ? ? ? ?
? 好 23 1.00 ? 1.00 ?
? 差 16 4.89(1.65～14.50) 0.004 1.21(0.18～7.99) 0.842
表3 经皮瓣修复乳腺巨大恶性肿瘤术后缺损患者总生存的单因素与多因素分析
因素 例数 单因素分析 多因素分析
HR值(95%CI) P值 HR值(95%CI) P值
临床分期 ? ? ? ? ?
? T4任何NM0 25 1.00 ? － ?
? T4任何NM1 21 2.38(0.77～7.36) 0.133 － －
肿瘤病理类型 ? ? ? ? ?
? 三阴性乳腺癌 10 1.00 ? 1.00 ?
? HER-2阳性乳腺癌 11 0.16(0.03～0.78) 0.024 0.41(0.07～2.37) 0.315
? luminal B型乳腺癌 18 0.17(0.04～0.70) 0.014 0.48(0.08～2.75) 0.408
? 乳腺间叶恶性肿瘤 7 0.13(0.02～1.10) 0.062 － －
切缘状况 ? ? ? ? ?
? 阴性 35 1.00 ? 1.00 ?
? 阳性 11 1.96(1.13～3.40) 0.016 1.57(0.32～7.59) 0.577
系统治疗反应性a ? ? ? ? ?
? 好 23 1.00 ? 1.00 ?
? 差 16 12.99(1.64～103.20) 0.015 6.15(0.48～79.33) 0.164
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