Does local recurrence affect the rate of distant metastases and survival in patients with early-stage breast carcinoma treated with breast-conserving therapy?
Does local recurrence affect the rate of distant metastases and survival in patients with early-stage breast carcinoma treated with breast-conserving therapy?
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DOI：
10.1002/cncr.11143
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发表时间：
2003-02-15
期刊：
影响因子：
6.2
通讯作者：
Martinez, A
中科院分区：
文献类型：
--
作者：
Vicini, FA;Kestin, L;Martinez, A
背景。本分析的目的是评估局部复发（LR）对接受保守手术（CS）和术后放疗（RT）的早期乳腺癌患者远处转移（DM）发展、总生存（OS）和病因特异性生存（CSS）的影响。1980 - 1995年间，1169例患者接受了CS并接受了rt。所有患者的随访时间均为1 ~ 10年，所有患者的淋巴结累及≤4个。中位随访时间为7.7年。采用Cox比例风险模型评价1,11对DM和CSS发展的影响。控制多种预后因素的抓取对分析也进行了比较有和没有1r的患者的结果。12年期的LR利率为11%。在整个人群中，与局部对照（LC）相比，1,11导致12年的OS和CSS发生率较低（分别为71%对81% [P = 0.001]和69%对88% [P < 0.001]）。在Cox多元回归模型中，LR是疾病特异性死亡率的显著预测因子。与LR相关的死亡率和糖尿病的风险比分别为2.69和2.67 （P < 0.001和P < 0.001）。无LR患者从手术到发展为DM的中位时间为3.8年，而LR患者为4.7年。发生LR的患者也有两个DM率高峰（2.5年和6.5年），而未发生LR的患者只有一个高峰（1.5年）。在小肿瘤（≤2.0 cm, P < 0.001）、淋巴结阴性（P = 0.004）或两者兼而有之（P < 0.001）的患者中，LR对DM的影响仍然明显。在手术床区以外复发的疾病对生存没有负面影响。在配对分析（控制年龄、肿瘤大小、分级、阳性淋巴结数和雌激素受体状态）中，LR仍然是最显著的死亡率预测因子（HR：死亡率，5.86；DM, 6.43）。目前的结果表明，LR可能是导致接受CS和rt的患者中DM和疾病特异性死亡率增加的原因。LR发生后DM时间分布的明显差异，以及源于手术床外的复发性疾病不影响OS的事实，加强了这一观点。这些数据加强了在接受保乳治疗的患者中确保最佳LC的必要性。
BACKGROUND. The purpose of the current analysis was to evaluate the impact of local recurrence (LR) on the development of distant metastases (DM), overall survival (OS), and cause specific survival (CSS) in patients with early-stage breast carcinoma who underwent conservative surgery (CS) and received postoperative radiotherapy (RT).METHODS. Between 1980 and 1995, 1169 patients underwent CS and received RT. All patients were followed for > 1 year and had less than or equal to 4 lymph nodes involved with disease. The median duration of follow-up was 7.7 years. A Cox proportional hazards model was performed to evaluate the effect of 1,11 on the development of DM and CSS. A snatched-pair analysis that controlled for multiple prognostic factors also was performed comparing the outcomes of patients with and without 1 R.RESULTS. The LR rate was 11% at 12 years. For the entire population, 1,11 led to poorer OS and CSS rates at 12 years compared with local control (LC) (71% vs. 81% [P = 0.001] and 69% vs. 88% [P < 0.001], respectively). In a Cox multiple regression model, LR was a significant predictor of disease specific mortality. The hazard ratio (HR) associated with LR was 2.69 for mortality and 2.67 for DM (P < 0.001 and P < 0.001, respectively). The median time from surgery to the development of DM was 3.8 years for patients without LR compared with 4.7 years for patients with LR. Patients who developed LR also had two peaks in the rate or DM (at 2.5 years and at 6.5 years) compared to only one peak (at 1.5 years) for patients who did not develop LR. The impact of LR on DM still was evident in patients with small tumors (≤ 2.0 cm; P < 0.001), negative lymph nodes (P = 0.004), or both (P < 0.001). Recurrent disease that developed outside of the surgical bed region had no negative effect on survival. In the matched-pair analysis (controlling for age, tumor size, grade, number of positive lymph nodes, and estrogen receptor status), LR remained the most significant predictor of mortality (HR: mortality, 5.86; DM, 6.43).CONCLUSIONS. The current results suggest that LR may be responsible for an increase in DM and disease specific mortality in patients who undergo CS and receive RT. This suggestion is reinforced by the distinct difference seen in the time distribution of DM after LR developed and by the fact that recurrent disease that originated outside of the surgical bed did not affect OS. These data reinforce the necessity to insure optimal LC in patients who are treated with breast-conserving therapy.