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中华普通外科学文献(电子版) ›› 2016, Vol. 10 ›› Issue (06) : 435 -440. doi: 10.3877/cma.j.issn.1674-0793.2016.06.013

所属专题： 文献；

论著

钙化对乳腺癌保乳术后预测价值的探讨
路忠志,1, 孙思敬1, 李敏1, 翟振1, 任小龙1, 马立群1, 祝清华1, 李东生1   
  1. 1. 255200　淄博市第一医院普外三科
  • 收稿日期:2016-03-30 出版日期:2016-12-01
  • 通信作者: 路忠志

Discussion on the predictive value of mammographic calcification for breast cancer patients treated with breast conserving surgery

Zhongzhi Lu,1, Sijing Sun1, Min Li1, Zhen Zhai1, Xiaolong Ren1, Liqun Ma1, Qinghua Zhu1, Dongsheng Li1   

  1. 1. The 3rd Department of General Surgery, Zibo City First Hospital, Zibo 255200, China
  • Received:2016-03-30 Published:2016-12-01
  • Corresponding author: Zhongzhi Lu
  • About author:
    Corresponding author: Lu Zhongzhi, Email:
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路忠志, 孙思敬, 李敏, 翟振, 任小龙, 马立群, 祝清华, 李东生. 钙化对乳腺癌保乳术后预测价值的探讨[J/OL]. 中华普通外科学文献(电子版), 2016, 10(06): 435-440.

Zhongzhi Lu, Sijing Sun, Min Li, Zhen Zhai, Xiaolong Ren, Liqun Ma, Qinghua Zhu, Dongsheng Li. Discussion on the predictive value of mammographic calcification for breast cancer patients treated with breast conserving surgery[J/OL]. Chinese Archives of General Surgery(Electronic Edition), 2016, 10(06): 435-440.

目的

探讨钙化对乳腺癌保乳术后局部复发、远处转移和总生存率的意义。

方法

回顾性分析淄博市第一医院2004年1月至2014年5月204例接受保乳术乳腺癌患者临床资料及随访结果。依影像学钙化情况分为钙化组及无钙化组，依钙化形态及分布方式进行生存分析。

结果

钙化组与无钙化组患者在肿瘤大小、组织学分级、区域淋巴结状态、激素受体及Her-2受体表达上差异无统计学意义。钙化组较无钙化组在局部复发、远处转移及乳腺癌相关死亡率上更高（RR 2.46、2.24、2.50，95% CI：1.11~5.44、1.19~4.24、1.06~5.86）。钙化形态亚组分析发现：大/粗钙化、仅超声提示钙化及无钙化患者较微小及多形性钙化患者局部无复发生存率（LRFS）及无病生存率（DFS）更低。钙化分布类型分析发现：线性或区段分布钙化（沿导管分布钙化）患者的LRFS（RR 6.20，95% CI：2.26~16.98）、DFS（RR 6.81，95% CI：2.86-16.20）及总生存率（OS）（RR 9.14，95% CI：2.53~33.00）较无钙化患者显著降低。钼靶上聚集钙化患者的LRFS、DFS及OS也较差，但与无钙化患者相比差异无统计学意义。线样/区段分布钙化的患者与无钙化、超声显示钙化及钼靶示良性钙化类型的患者相比，常伴有广泛导管内癌成分（EIC）。有EIC较无EIC患者的局部复发率更高，但在乳腺癌相关死亡率及远处转移率上差异无统计学意义。

结论

乳腺癌伴钙化，尤其是沿导管分布钙化的患者接受保乳手术后局部复发率较高，并影响远期预后。仅超声提示钙化的患者保乳术后近期及远期预后不受影响。EIC是钙化患者保乳术后局部复发的预测指标之一。

关键词: 乳腺肿瘤, 复发, 肿瘤转移, 无病生存
Objective

To study the significance of mammographic calcification for local recurrence, metastasis and overall survival for breast cancer patients treated with breast conserving surgery (BCS).

Methods

The records of two hundred and four patients of breast carcinoma treated with BCS from January 2004 to May 2014 were reviewed. The results of mammograms and breast untrasound (BUS) tests were available for all those patients. The patients were classified as those without calcification on both mammograms and BUS, those with calcification on mammograms, and those with calcification on BUS but not mammograms; the latter two groups were collectively named patients with calcification. Survival rates were performed with respect to morphologic types and distribution patterns of calcification.

Results

Median follow-up was 85 months. Pathologic characteristics of patients with and without calcification were not statistically different with respect to tumor size, histologic grade, regional lymph node metastasis, hormonal receptor expression, and Her-2 status. Survival analysis found that patients with calcification had significantly higher risk of local recurrence, distant metastasis, and breast cancer-associated death after BCS [relative risk (RR) and 95% CI: 2.46, 1.11-5.44; 2.24, 1.19-4.24; 2.50, 1.06-5.86, respectively]. Subgroup analysis according to morphology of calcification revealed that local relapse free survival (LRFS), disease free survival (DFS), and overall survival (OS) were significantly lower in patients with large/coarse calcification, BUS calcification, and those without calcification, compared with those with microcalcification and pleomorphic calcification. Further survival analyses were performed by the distribution patterns of calcification and showed that patients with calcification of liner and segmental distribution, or calcification spreading along the ducts, had significantly lower LRFS (RR 6.20, 95% CI: 2.26-16.98), DFS (RR 6.81, 95% CI: 2.86-16.20), and OS (RR 9.14, 95% CI: 2.53-33.00), compared with those without calcification. Patients with mammographic calcification of clustered distribution also showed trends of lower LRFS, DFS, and OS, without significant difference. Patients with calcification of liner/segmental distribution were more often accompanied with extensive intraductal component (EIC), compared with those without calcification, with BUS calcification, and with calcification of clustered distribution (P<0.001). The rates of local recurrence were significantly higher in patients with EIC than in those without EIC. The rates of isolated distant metastasis and breast cancer-associated death in patients with calcification who had tumors with or without EIC were not statistically different.

Conclusions

Patients with calcification, especially spreading along the ducts, have higher risk of local failure after BCS, which has negative impacts on long-term survival. Calcification found in BUS tests does not influence the short-and long-term outcome of patients treated with BCS. Existence of EIC is a predictive factor of local failure in patients with calcification treated with BCS.

Key words: Breast neoplasms, Recurrence, Neoplasm metastasis, Disease-free survival
表1 钙化组与无钙化组患者一般资料的比较[例（%）]
项目 钙化组 无钙化组 统计值 P值
例数 85 119 ? ?
平均年龄（岁， ± s） 50±3.2 51±2.6 ? ?
是否绝经 ? ? 0.049 0.888
? 是 43(50.6) 62(52.1) ? ?
? 否 42(49.4) 57(47.9) ? ?
手术方式 ? ? 0.712 0.765
? 象限切除 81(95.3) 112(93.8) ? ?
? 肿块切除 4(4.7) 7(6.2) ? ?
新辅助化疗 ? ? 0.176 0.310
? 否 82(96.3) 118(99.2) ? ?
? 是 3(3.7) 1(0.8) ? ?
组织学类型 ? ? 2.033 0.782
? 浸润性导管癌 68(79.1) 96(80.7) ? ?
? 浸润性小叶癌 2(2.3) 4(3.4) ? ?
? 导管原位癌 2(2.3) 1(0.8) ? ?
? 其他 13(15.3) 18(15.1) ? ?
组织学分级 ? ? 1.965 0.524
? G1 16(18.8) 19(15.9) ? ?
? G2 54(64.5) 86(72.3) ? ?
? G3 15(17.6) 14(11.8) ? ?
肿瘤分期 ? ? 0.534 0.510
? T1 65(76.5) 98(82.4) ? ?
? T2 18(21.2) 20(16.8) ? ?
? T3 2(2.3) 1(0.8) ? ?
腋窝淋巴结状态 ? ? 0.281 0.298
? 阴性 65(76.5) 98(82.4) ? ?
? 阳性 20(23.5) 21(17.6) ? ?
ER/PR状态 ? ? 0.435 0.622
? 阳性 65(76.5) 87(73.1) ? ?
? 阴性 20(23.5) 32(26.9) ? ?
Her-2状态 ? ? 0.466 0.522
? 阳性 12(14.1) 13(10.9) ? ?
? 阴性 73(85.9) 106(89.1) ? ?
辅助化疗 ? ? 0.019 1.000
? 是 10(11.8) 14(11.8) ? ?
? 否 75(88.2) 105(88.2) ? ?
表2 有、无钙化组患者复发率、远处转移率及相关死亡率的比较[例（%）]
项目 钙化组(%) 无钙化组(%) RR(95%CI) P值
局部/区域复发 ? ? 5.488(1.195~25.204) 0.013
? 是 8(9.4) 2(1.7) ? ?
? 否 77(90.6) 117(98.3) ? ?
远处转移 ? ? 3.150(1.003~9.893) 0.037
? 是 9(10.6) 4(3.4) ? ?
? 否 76(89.4) 115(96.6) ? ?
相关死亡 ? ? 4.901(1.044~23.008) 0.036
? 是 7(8.2) 2(1.7) ? ?
? 否 78(91.8) 117(98.3) ? ?
图1 乳腺癌保乳术后患者LRFS、DFS、OS生存期比较
表3 不同钙化类型与分布方式患者的组织学分级（G1、2、3）[例（%）]
项目 G1 G2+3 OR(95%CI)a P值
形态 ? ? ? 0.321
? 无钙化 19(15.8) 101(84.2) 1.00 ?
? 超声钙化+良性钙化 5(16.1) 26(83.9) 1.306(0.41~4.15) ?
? 微/多形性钙化 11(20.8) 42(79.2) 0.724(0.31~1.68) ?
分布 ? ? ? 0.076
? 无钙化 19(15.8) 101(84.2) 1.00 ?
? 超声钙化+良性钙化 5(17.9) 23(82.1) 1.305(0.41~4.14) ?
? 聚集 10(25.6) 29(74.4) 0.573(0.23~1.39) ?
? 沿导管漫延 1(5.9) 16(94.1) 2.092(0.17~3.50) ?
表4 不同钙化类型与分布患者的区域淋巴结情况[例（%）]
项目 L(-) L(+) OR(95%CI)a P值
形态 ? ? ? 0.126
? 无钙化 96(82.1) 21(17.9) 1.000 ?
? 超声钙化+良性钙化 21(75.0) 7(25.0) 1.355(0.59~3.11) ?
? 微/多形性钙化 45(76.3) 14(23.7) 1.557(0.80~3.01) ?
分布 ? ? ? 0.711
? 无钙化 96(82.1) 21(17.9) 1.000 ?
? 超声钙化+良性钙化 21(77.8) 6(22.2) 1.356(0.59~3.11) ?
? 聚集 32(76.2) 10(23.8) 1.623(0.78~3.36) ?
? 沿导管漫延 13(72.2) 5(27.8) 1.361(0.43~4.31) ?
图2 乳腹癌保乳术后患者钙化类型及分布方式的LRFS，DFS，OS
表5 乳腺癌患者钙化分布方式与广泛导管内成分情况及预后[例（%）]
项目 无EIC 有EIC χ2值 P值
钙化分布方式 ? ? 8.961 <0.001
? 无钙化 118(99.2) 1(0.8) ? ?
? 超声钙化+良性钙化 24(96.0) 1(4.0) ? ?
? 聚集 38(88.4) 5(11.6) ? ?
? 沿导管漫延 13(76.5) 4(23.5) ? ?
预后 ? ? ? ?
? 局部/区域复发 ? ? 4.936 0.022
? 是 2(15.4) 3(75.0) ? ?
? 否 11(84.6) 1(25.0) ? ?
? 远处转移 ? ? 1.303 0.247
? 是 4(30.8) 2(66.7) ? ?
? 否 9(69.2) 1(33.3) ? ?
? 相关死亡 ? ? 0.461 0.473
? 是 2(15.4) 1(33.3) ? ?
? 否 11(84.6) 2(66.7) ? ?
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