摘要目的 分析191例早期乳腺癌保乳术后患者,探讨不同放化疗顺序对不同高危因素患者预后的影响.方法 回顾性分析自2006年1月1日至2015年12月31日大连医科大学附属第二医院收治的191例早期乳腺癌保乳术后患者(T1-1N0-1M0)临床资料.按放化疗顺序分为先放疗组、先化疗组和化疗-放疗-化疗组(“三明治组”).先放疗组32例、先化疗组107例、三明治组52例.对各组病例的年龄、是否绝经、肿瘤大小(T1、T2)、淋巴结转移情况、病理学类型、脉管癌栓、分子分型、手术放疗间隔时间等因素进行单因素及多因素分析,寻找影响患者预后的独立危险因素.比较存在不同高危因素的患者在先放疗组、先化疗组、三明治组中5年局部复发(LRR)和总生存(OS)的差异.结果 肿瘤大小、淋巴结转移情况、脉管癌栓、手术放疗间隔时间是影响5年OS的独立危险因素.先放疗组、先化疗组、三明治组中T1、T2期患者的5年LRR和OS比较,差异均无统计学意义(P＞0.05).先放疗组、先化疗组与三明治组淋巴结转移N0期患者5年LRR比较,差异无统计学意义(P＞0.05).先化疗组和三明治组N1期患者5年LRR分别为4.5％和16.2％,两组差异有统计学意义(x2=4.813,P=0.028).先化疗组和三明治组N1患者5年OS差异无统计学意义(P＞0.05).先放疗组、先化疗组、三明治组有脉管癌栓患者5年LRR分别为5.3％、9.2％、18.1％ (P＞0.05);5年OS分别为61.5％、90.1％、87.2％(x2=6.282,P=0.043).3组无脉管癌栓患者5年LRR、OS比较,差异均无统计学意义(P＞0.05).先放疗组、先化疗组、三明治组手术放疗间隔时间≤6个月的患者5年LRR差异均无统计学意义(P＞0.05).手术放疗间隔时间＞6个月均为先化疗组,先化疗组中手术放疗间隔≤6个月与＞6个月患者的5年LRR为5.2％和14.1％(x2 =4.886,P=0.027),OS分别为96.9％和85.7％(x2 =5.758,P=0.038).结论 临床治疗时根据个体化选择方案.对于腋窝淋巴结阴性而局部存在复发高危因素的患者,可以先进行放疗;对于腋窝淋巴结转移或脉管癌栓的高危患者,应早期开始化疗,放疗可以延迟,但不能超过6个月.

abstractsObjective To investigate the prognostic factors affecting early breast cancer patients with conserving surgery and discuss the influences of chemoradiation sequence on treatment efficacy.Methods We retrospectively analyzed 191 cases of early breast cancer after breast conservation surgery in the second hospital of Dalian medical university,from January 1,2006 to December 31,2015.According to the treatment order,they were divided into radiotherapy group,chemotherapy group and sandwich group.There were 32 patients in the radiotherapy group,107 patients in the chemotherapy group,and 52 patients in the sandwich group.The sandwich group was treated with chemotherapy-radiotherapy-chemotherapy.The factors were analyzed independently from the patients' age,menopausal status,pathology type,tumor size (T1,T2),axillary lymph node,molecular type of breast cancer,the interval between surgery and radiation,vascular tumor emboli.Regression model was used to find the risk factors of early stage breast cancer patients with conserving surgery.The 5-year LRR and 5-year OS was compared among radiotherapy-first group,chemotherapy-first group,the sandwich group in patients with high risk factors,and the factors associated with the prognosis of patients were analysed.Results The Multivariate Cox Regression model showed that tumor size,axillary lymph node,vascular tumor emboli,the interval between surgery and radiation were independent risk factors associated with 5-year OS.Among patients with T1 and T2 stage in radiotherapy-first group,chemotherapy-first group,sandwich group,there was no statistical difference in 5-year LRR or 5-year OS (P ＞ 0.05).Among patients with N0 stage in radiotherapy first group,chemotherapy first group,sandwich group,5-year LRR were not statistically different (P ＞ 0.05).For patients with N1 stage in chemotherapy-first group and the sandwich group 5-year LRR were with statistical difference(x2 =4.813,P =0.028).OS were without statistical difference (P ＞ 0.05).In patients with vascular tumor emboli in radiotherapy-first group,chemotherapy-first group,the sandwich group,5-year LRR were without statistical difference (5.3％,9.2％,vs.18.1％,P ＞ 0.05),OS were statistically different (61.5％,90.1％ vs.87.2％,x2 =6.282,P =0.043).For patients without vascular tumor emboli,there was no statistical difference in 5-year LRR (P ＞ 0.05).For patients started radiation within 6 months after surgery in radiotherapy-first group,chemotherapy-first group,the sandwich group,5-year LRR were without statistical difference (P ＞ 0.05).However,patients in chemotherapy-first group the time interval surgery and radiation ≤6 months vs.＞6 months 5-year LRR was 5.2％ and 14.1％ (x2 =4.886,P=0.027),5-year OS were 96.9％ and 85.7％ (x2 =5.758,P =0.038).Conclusions Clinical treatment is based on individualized options.For patients with negative axillary lymph nodes,but high risk factors for local recurrence,radiotherapy may be performed firstly.For high-risk patients with axillary lymph node metastasis or vascular tumor embolus,chemotherapy should be started early and radiotherapy may be followed,but not more than 6 months.