Treatment outcome and patterns of failure in breast cancer patients with locoregional recurrence after mastectomy

經乳房切除乳癌病患之局部區域性復發的表現及治療預後

郭頌鑫 ； 成佳憲 ； 黃俊升 ； 郭文宏 ； 簡君儒 ； 丁禮莉 ； 鄭安理

《放射治療與腫瘤學》 13卷3期 (2006/09) Pp. 163-173

https://doi.org/10.6316/TRO/200613(3)163

摘要

目的：目前研究證據認為， 當經乳房切除之乳癌病患發生局部區域復發時， 通常與致病性和全身性轉移有高相關性。因此， 本研究是希望能釐清:是否藉由加強局部治療， 去進一步防止乳癌 再度復發， 和全身性轉移， 並進而改善存活率。
材料和方法：自1992 年1 月至2001 年12 月間， 從臺大醫院癌症登記室之資料庫中， 符合經乳房全切除後之病患， 且發生局部復發， 但同時並無併發遠處轉移， 並經局部治療之病患， 被選出回顧。同側局部復發被定義為： 局部乳癌之復發， 只局限於同側之胸壁、切除後乳房之疤痕區域、上鎖骨區域、下鎖骨區域， 內乳房等淋巴區域。若復發區域發生在上述區域之外，則稱為遠處轉移。總共60 位病患，其平均年齡為47 歲（29 歲至75 歲），進入此研究。最常復發之區域為同側之胸壁和切除後乳房之疤痕區域， 此比例為62%。上鎖骨，下鎖骨區域其發生率為
22%。而腋下及內乳房淋巴結之發生率為16%。其中54 位病患，接受局部切除後， 再接受放射線治療。而其他6 位病患，則接受放射線治療來作為第一線治療。在這些病患中， 有36 位只接受單獨局部區域放射線治療，而其他24 位則接受局部性和選擇性局部區域之放射線治療（治療容量包括同側胸壁和局部淋巴區域）。其中68.3% 之復發病患，則接受追加性全身治療如： 賀爾蒙治療、或化學治療、或合併賀爾蒙和化學治療。
結果：病人的中位數追蹤期為51.5 個月。同側胸壁復發之患者，其復發後之4 年存活率為67%。而腋下、上鎖骨區域、下鎖骨區域之復發患者，其復發後之4 年存活率則為56%。進一步分析顯示，其復發後之4 年無病存活率，在胸壁復發這組和胸壁外復發這組則分別為56％和52 ％ 。相對於晚期復發之患者（無病之時間間隔至少兩年以上），其復發後之4 年存活率為76 ％，而早期復發之患者（ 無病之時間間隔小於或等於兩年），其復發後之4 年存活率則為39％（P 值等於0.04）。相對於患者接受局部區域放射線治療之高局部復發率為22.2%，而接受局部和選擇區域放射線治療之患者，其局部復發率則降低很多為8.3%。相對於只接受單獨局部區域放射線治療之患者，其復發後之4 年存活率為55％ 、而無病存活率為48%；而接受局部性和選擇性局部區域之放射線治療之患者，其復發後之4 年存活率則為69 ％ 、而無病存活率則為57%（存活率：P 值等於0.21；無病存活率：P 值等於0.24）。進一步分析顯示，患者接受追加性全身治療，其復發後之4 年存活率為64 ％、而無接受追加性全身治療之患者，其復發後之4年存活率則為43％（P 值等於0.08 ）。同樣的、相對於無接受追加性全身治療之患者， 其復發後之4 年無病存活率為33 ％，而接受追加性全身治療之患者，其復發後之4 年無病存活率則為60%（P 值等於0.38 ）。
結論：仍有一部份之患者在經積極局部治療後， 仍可享受很好的總存活率， 和很長時間的無病存活率。因此， 在面對全乳房切除後之乳癌患者， 若發生單獨同側局部復發， 應給予積極局部 治療， 以提供適當的局部控制， 和防止第二度轉移。

並列摘要

Purpose : Recent data suggest that postmastectomy patients with locoregional recur-rences are frequently associated with considerable morbidity and present with sys-temic failure. The present study sought to clarify the correlation of radical locoregional therapy with the prevention of further local recurrence, secondary spread, and the improvement of survival.
Materials and Methods : Breast cancer patients who were treated for an isolated postmastectomy locoregional recurrence without simultaneous evidence of distant metastasis were selected from 1992 to 2001. Isolated locoregional recurrence (ILRR)
was defined as any recurrence of tumor in the ipsilateral chest wall, mastectomy scar, supraclavicular, infraclavicular, axillary, or internal mammary lymph node (LN), with no
other metastasis. A total of 60 patients, with a median age of 47 years (range 29-75 years) were included. The majority of recurrences occurred at the chest wall and around the mastectomy scar (62%). Supra- or infraclavicular LN recurrence represent-
ed 22% of all ILRR, and axillary failure represented 16%. Fifty-four patients received irradiation after local tumor excision. Six patients had received radiotherapy as part of their primary treatment. In these cases, the involved-field radiotherapy was given in 36 patients, while 24 patients were treated with both involved-field and elective-field (chest wall and regional lymphatics) locoregional irradiation. Adjuvant systemic therapy con-sisting of either tamoxifen, cytotoxic chemotherapy, or both, along with the recurrent tumor, had been applied in 68.3% of patients.
Results : With a median follow-up of 51.5 months, the 4-year actuarial overall survival (OS) after ILRR was 67% for patients with chest wall recurrence. Patients with either axillary, supra- or infraclavicular- recurrence had a 4-year OS of 56%. The 4-year disease-free survival (DFS) for chest wall recurrence and either axillary, supra- or infra-clavicular- recurrence was 56% and 52%, respectively. Seventy-six percent of patients
with a disease-free interval of at least 2 years (late relapse) survived 4 years follow-ing ILRR, as compared to 4-year OS of 39% in those with disease-free interval of less than 2 years (early relapse) (P = .04). The incidence of second ILRR was 8.3% with both involved- and elective-field locoregional irradiation as compared to 22.2% with involved-field irradiation alone. Patients who were treated with both involved-field and
elective-field locoregional irradiation had the 4-year OS of 69%, and the 4-year DFS of 57%, compared to 55% and 48% of those who were treated with involved-field radiation alone (OS, P = .21; DFS, P = .24). Furthermore, 64% patients who had been treated with adjuvant systemic therapy survived 4 years following ILRR, as compared to 43% for those without additional systemic therapy (P = .08). Similarly, recurrent patients
with adjuvant systemic therapy experienced a 4-year DFS of 60%, compared with 33% for patients without systemic therapy after ILRR (P = .38) Conclusion : A substantial portion of postmastectomy patients with locoregional recur-rence sustain an unexpected long DFS and OS after curative therapy. Therefore, com-prehensive radiotherapy should be used to provide optimal locoregional control and to prevent secondary dissemination in patients with ILRR.