乳房乳管原位癌患者接受乳房保留手術合併放射線治療：預後因子分析

Ductal Carcinoma in Situ of the Breast Treated with Partial Mastectomy and Radiation Therapy

黃家俊(Chia-Chun Huang) ； 劉幕台(Mu-Tai Liu) ； 張東浩(Tung-Hao Chang) ； 畢祖平(Chu-Ping Pi)

《放射治療與腫瘤學》 11卷1期 (2004/03) Pp. 17-25

https://doi.org/10.6316/TRO/200411(1)17

摘要

目的：乳房保留手術合併放射線治療對於乳房乳管原位癌的患者來說是一個標準的治療方法。本研究的目的在分析乳房保留手術合併放射線治療，對於乳房乳管原位癌患者的治療結果，以及探討影響預後的因子。 材料與方法：從1992年12月至2003年7月，共有29位女性在彰化基督教醫院被診斷為乳房的乳管原位癌，並接受乳房保留手術合併放射線治療。病人的年齡中位數是46歲。乳房腫瘤是經由理學檢查（17%）、乳房超音波（28%），以及乳房攝影（55%）所偵測到。腫瘤的大小中位數是2.0公分。腫瘤大部分位於左側乳房（66%），且以外上四分之一的位置居多（59%）。有8位病人（28%）接受了腋下哨兵淋巴結的切片檢查。在手術切除邊緣情況方面，14位病人（48%）的邊緣沒有腫瘤細胞，6位病人（21%）則在切除邊緣發現有殘留的腫瘤細胞。在病理報告的次項分類方面，13位病人（45%）是 comedo type，4位病人（14%）是papillary type，3位病人（10%）是cribriform type，2位病人（7%）是solid type，7位病人（24%）則是沒有提到次項分類。10位病人（35%）是屬於高度惡性（high-grade）的乳管原位癌。16位病人（55%）在病理報告發現有腫瘤壞死（tumor necrosis）情形。患側乳房的放射線劑量中位數是46 Gy。腫瘤部位的加強（boost）放射線劑量中位數是16 Gy。在完成放射線治療的療程之後，有13位病人（45%）接受荷爾蒙治療（tamoxifen，每天20 mg）。在統計方面，存活率分析使用Kaplan-Meier，單變項分析使用log rank test。 結果：這29位病人的追蹤期間從3個月至127個月不等，中位數是25個月。全部29位病人在最近一次的追蹤都仍然存活著。在28位沒有任何腫瘤復發或是遠端轉移的病人中，11位病人存活了30個月以上。其中有一位病人存活長達10年並且持續定期追蹤當中。在全部29位病人當中，只有一位（3%）在追蹤了4.5年之後發現有腫瘤復發。在存活率方面，三年與五年的整體存活率（overall survival）皆為100%。三年與五年的無病存活率（disease-free survival）分別是 100%與80%。三年與五年的疾病相關存活率（disease-specific survival）皆為100%。在美觀滿意度方面，25位病人（86%）有優秀（excellent）的美觀滿意度，其餘4位病人（14%）則為良好（good）的美觀滿意度。以log rank test對所有變數作單變項分析之後，發現腫瘤是否壞死（tumor necrosis，p = 0.0455），腫瘤惡性程度（tumor grade，p = 0.0455），手術切除邊緣是否乾淨（resection margin，p = 0.0455），對於無病存活率來說是重要的預後因子。 結論：研究結果顯示，乳房保留手術合併放射線治療的整體存活率為100%，復發率為3%。預後變數當中，腫瘤是否壞死，腫瘤惡性度，手術切除邊緣是否乾淨，對於無病存活率來說是重要的預後因子。此三項因子的有無就個別比較上對病人的無病存活率在統計上有差異，至於是否為獨立（independent）預後因子則需更多資料與數據作多變數分析才能得知。這些分析結果可以在對於有高危險因子的乳管原位癌是否應該接受更積極的治療時，提供更多的參考資訊。未來應該要有更大型的研究與更長的追蹤時間，針對以乳房保留手術合併放射線治療的乳管原位癌病患作更進一步的分析。

關鍵字

乳管原位癌 ； 乳癌 ； 乳房保留手術 ； 放射線治療

並列摘要

Purpose : Partial mastectomy and radiation therapy is a treatment option for patients with ductal carcinoma in situ (DCIS) of breast. The aim of our study is to evaluate the outcome and analyze prognostic factors in patients with DCIS of breast treated with partial mastectomy and radiation therapy. Materials and Methods : From December 1992 through July 2003, there were 29 women diagnosed with DCIS of breast receiving the treatment of partial mastectomy and radiation therapy at our institution. The median age of diagnosis was 46 years. The median tumor size was 2.0 cm. The tumor was predominantly at left-side breast (66%), and the outer upper quadrant was the main location (59%). Sentinel axillary lymph node biopsy was performed in 8 patients (28%). The resection margin was free in 14 patients (48%), and positive in 6 patients (21%). The subtypes of pathological report were comedo type in 13 patients (45%), papillary type in 4 patients (14%), cribriform type in 3 patients (10%), solid type in 2 patients (7%), and not specified in 7 patients (24%). Ten patients had high-grade DCIS (35%). Necrosis of tumor was found in 16 patients (55%). The median radiation dose to the breast was 46Gy. The median dose of tumor bed boost was 16Gy. After completion of radiation therapy, hormone therapy with tamoxifen 10mg twice daily was administered to 13 patients (45%). Results : All 29 patients were alive until the latest follow-up. The median duration of follow-up was 25 months (range: 3 to 127 months). Among 28 patients without any regional recurrence or distant metastasis, 11 patients survived for more than 30 months. Only one out of 29 patient (3%) had regional recurrence after follow-up for 4.5 years. Three-year overall survival rate was 100%, and five-year overall survival rate was 100%. Three-year disease free survival rate was 100%, and five-year disease free survival rate was 80%. Three-year disease specific survival rate was 100%, and three-year disease specific survival rate was 100%. Twenty-five patients (86%) had excellent cosmetic results, and 4 patients (14%) had good cosmetic results. In univariate analysis of variables with log rank test, tumor necrosis, tumor grade, and resection margin were significant in predicting disease free survival. Conclusion : The good survival outcome and low local recurrence rate suggested the treatment with partial mastectomy and radiation therapy was a good option of treatment for DCIS of breast. Tumor necrosis, tumor grade, and resection margin were prognostic factors on disease free survival. Larger study series with longer follow-up period should be warranted to make advanced analysis in patients with DCIS receiving treatments of partial mastectomy and radiation therapy.

並列關鍵字

ductal carcinoma in situ ； breast cancer ； partial mastectomy ； radiation therapy