| Objective: Breast cancer is the most common malignant tumor of female in the world, which seriously threatening those health and lives.It was proved that about 7%~10% malignant tumor was breast cancer. In recent years, the incidence of breast cancer keeps on rising in China and the age of onset is younger. For breast cancer, the lymphatic metastasis is the most common approach to metastasis. Primary breast cancer can be a local diffusion. But at the same time, it can be metastasised through the internal mammary lymph nodes to the contralateral breast, or metastasis to the axillary lymph node and peripheral node. Internal mammary lymph nodes is the second important route of metastasis than axillary lymph node, which is an important basis to determining the pathological staging prognosis and planning adjuvant therapy[1-3]. In 1921, Handley has first discovered the route of metastasis which through internal mammary lymph nodes. However, the choice of operation scheme for locally advanced breast cancer with internal mammary lymph node metastasis is still a problem. The IM lymph node chain is represented by a variable number of lymph nodes(average of 6) situated behind the intercostal muscles and costal cartilages. The nodes are generally located close to the IM vein and artery, and more often in the first, second, and third spaces. In this paper, 80 cases of locally advanced breast cancer patients which has internal mammary lymph node positive after combined therapy were reviewed, analysis the relative factors of the breast cancer prognosis. In order to provide a reference for the treatment and prognosis of the patients with internal mammary lymph node metastasis.Methods: This study collected the Fourth Hospital of Hebei Medical University, Breast Center during the 2010 January to 2013 December cases of surgical patient data. We found internal mammary lymph node positive in 94 cases. We selected 80 cases which have complete data and all the patients were not receiving preoperative radiotherapy and endocrine therapy. Recording the age, tumor size, histological type, grade, lymphovascular invasion, the positive number of lymph node, and whether or not accept the new adjuvant chemotherapy, surgical. Used immunohistochemical to detect the expression of ER, PR, HER-2 and Ki-67 in those tissues. All patients were followed up, recorded the disease free survival time and overall survival time. Then, analysised the data combined with clinical and pathological indexes. Used SPSS 19.0 software to analyze the relative factors of disease free survival and overall survival. The univariate asurvival analysis using the Kaplan-Meier method, the significant examination and differences by using log-rank. The multivariate analysis of these individual variables were performed by Cox proportional hazard model. All tests were performed at the 0.05 level of significances.Results:1 General data results: All the 80 female patients was primary unilateral breast cancer. The TNM stages was IIIC. All the 80 female patients’ age was 27~79 years old. The median age was 53 years. Under 35 years old: 8 cases(10%); more than 35 years old: 72 cases(90%). Premenopausal patients: 36 cases(45%), postmenopausal patients: 44 cases(55%). Tumor size: T1(2cm): 35 cases(43.75%); T2(2 ~ 5cm): 27 cases(33.75%); T3(> 5cm): 18 cases(22.5%). Histologic type: Infiltrating ductal arcinoma: 77 cases(96.25%); other: 3 cases(3.75%). Tumor subtype: Luminal A: 12 cases(15%); Luminal B: 30 cases(37.5%);HER-2: 25 cases(31.25%);Triple negative: 13 cases(16.25%). Lymphovascular invasion: yes: 45 cases(56.25%); no:35 cases(43.75%). Postoperative histopathological grade: I: 13 cases(16.25%);II: 38 cases(47.5%); III: 29 cases(36.25%).The number of positive lymph nodes: 1-3 : 14 cases(17.5%); 4-9 : 25 cases(31.25%); more than 9: 41 cases(51.25%).Surgery: Modified radical mastectomy: 41 cases(51.25%); Modified radical mastectomy+IMLND: 39 cases(48.75%).All the patients were accept radiotherapy. All patients received neoadjuvant chemotherapy in 35 cases, some reasons such as older age, physical condition, ower economic make 45 cases of patients can not accept neoadjuvant chemotherapy. All patients accept adjuvant chemotherapy, according to the ER, PR and HER-2 decide whether to accept the endocrine therapy and targeted therapy or not.2 The follow-up results:The the follow-up end to 2014 August or death,94 patients meet the requirements.8 patients were lost in follow-up, 6 patients died due to other reasons, so 80 patients finally get into the group. Followed up for 10 ~ 55 months, the median follow-up time was 26 months. The follow-up rate was 87.2%.31 cases(38.75%) were survival without disease. 49 cases(61.25%) occurrence local recurrence or distant metastasis, 18 cases(22.5%) of them were death due to breast cancer.3 The Kaplan-Meier for DFS, OS and clinical pathological index3.1 The Kaplan-Meier for DFS and clinical pathological index3.1.1 Age and DFS: less than 35 year old age group: DFS for 6 ~ 39 months, the median DFS was 27.5 months; more than 35 year oldage group: DFS for 5~47 months, the median DFS was 39.3 months. Analysis by log-rank test, no significant difference between two groups(x2=1.525, P=0.217).3.1.2 Neoadjuvant therapy and DFS: Not accept neoadjuvant therapy group: DFS for 6~46 months, the median DFS was 33.3 months; accept neoadjuvant therapy group: DFS for 11~47 months, the median DFS was 44.1 months. Analysis by log-rank test, there is significant difference between two groups(x2=7.931, P =0.005).3.1.3 Surgery mode and DFS: Modified radical mastectomy group: DFS for 6 ~ 43 months, the median DFS was 30.7 months; Modified radical mastectomy+internal mammary lymph node dissection group: DFS for 15~47 months, the median DFS was 43.9 months. According to log-rank test, there is significant difference between two groups(x2=11.442, P =0.001).3.1.4 Tumor size and DFS:p T1 group: DFS for 6~47 months, the median DFS was 43.9 months; p T2 group: DFS for 5~45 months, the median DFS was 34.8 months; p T3+ p T4 group: DFS for 6~35 months, the median DFS was 28.5 months. Analysis by log-rank test, there is significant difference between three groups(x2=7.162, P =0.028).3.1.5 Histological grade and DFS:I grade group: DFS for 10~30 months, the median survival time was 27.2 months; II grade group: DFS for 5 ~ 46 months, the median survival time was 36.3 months; III gradegroup: DFS for 6~47 months, the median DFS was 40.1 months. According to log-rank test, no significant difference between three groups(x2=1.049, P =0.592>0.05).3.1.6 The number of positive lymph nodes and DFS: ≤3 groups: DFS for 6~47 months, the median DFS was 34.4 months; 4-9 group: DFS for 11~45 months, the median DFS was 39.6 months; ≥10 groups: DFS for 5 ~ 44 months, the median DFS was 36.5 months. Analysis by log-rank test, no significant difference between three groups(x2=1.631, P =0.442).3.1.7 Lymphovascular invasion: without vascular tumor thrombus group: DFS for 9 ~ 46 months, the median DFS was 38.6 months; with tumor thrombus group: DFS for 6~47 months, the median DFS was 38 months. By log-rank test, no significant difference between two groups(x2=0.291, P=0.589).3.1.8 Tumor subtype and DFS: Luminal A group: DFS for 16~47 months, the median DFS was 41.9 months; Luminal B group: DFS for 10~43 months, the median DFS was 40.8 months; HER-2group: DFS for 6 ~ 39 months, the median DFS was 33.1 months; triple negative group: DFS for 5 ~ 25 months, the median DFS was 14.1 months. By log-rank test, there is significant difference between four groups(x2=33.579, P< 0.001).3.1.9 Histologic type and DFS: Infiltrating ductal arcinoma group: DFS for 5~47 months, the median DFS was 36.2 months; other type group: DFS for 27 ~ 35 months, the median DFS was 32.3 months. By log-rank test, no significant difference between two groups(x2=0.860, P=0.354).3.2 The Kaplan-Meier for OS and clinical pathological index3.2.1 Age and OS: less than 35 year old age group: OS for 8~55 months, the median OS was 38.9 months; more than 35 year old age group: OS for 8~50 months, the median OS was 42.7 months. Analysis by log-rank test, no significant difference between two groups(x2=1.329, P=0.249).3.2.2 Neoadjuvant therapy and OS: Not accept neoadjuvant therapy group: OS for 8~50 months, the median OS was 37.5 months; accept neoadjuvant therapy group: OS for 13~55 months, the median OS was 51.6 months. Analysis by log-rank test, there is significant difference between two groups(x2=8.561, P=0.003).3.2.3 Surgery mode and OS: Modified radical mastectomy group: OS for 8~43 months, the median OS was 31.1 months; Modified radical mastectomy+ internal mammary lymph node dissection group: OS for 17~55 months, the median OS was 50.8 months. According to log-rank test, there is significant difference between two groups(x2=14.634, P=0.001).3.2.4 Tumor size and OS: p T1 group: OS for 8~55 months, the median 0S was 50.1 months; p T2 group: OS for 8~50 months, the median OS was 40.1 months; p T3+ p T4 group: OS for 8~41 months, the median OS was 30.1 months. Analysis by log-rank test, there is significant difference between three groups(x2=8.153, P=0.017).3.2.5 Histological grade and OS: I grade group: OS for 8~55 months, the median survival time was 47.0 months; II grade group: OS for 8~50 months, the median survival time was 41.2 months; III gradegroup: OS for 16~30 months, the median OS was 28.2 months. According to log-rank test, no significant difference between three groups(x2=0.493, P=0.782).3.2.6 The number of positive lymph nodes and OS: ≤3 groups: OS for 8~50 months, the median OS was 40.1 months; 4-9 group: OS for 15~55 months, the median OS was 48.2 months; ≥10 groups: OS for 8~44 months, the median DFS was 37.5 months. Analysis by log-rank test, no significant difference between three groups(x2=1.229, P=0.541).3.2.7 Lymphovascular invasion and OS: without vascular tumor thrombus group: OS for 13~50 months, the median OS was 43.9 months; with tumor thrombus group: OS for 8~55 months, the median DFS was 43.8 months. By log-rank test, no significant difference between two groups(x2=0.366, P=0.545).3.2.8 Tumor subtype and OS: Luminal A group: OS for 16~46 months, the median OS was 42.8 months; Luminal B group: OS for 13~43 months, the median OS was 41.2 months; HER-2group: OS for 8~55 months, the median OS was 45.8 months; triple negative group: OS for 8~25 months, the median OS was 20.8 months. By log-rank test, there is significant difference between four groups(x2=35.376, P=0.001).3.2.9 Histologic type and OS: Infiltrating ductal arcinoma group: OS for 8~55 months, the median OS was 40.2 months; other type group: OS for 28~41 months, the median OS was 37.4 months. By log-rank test, no significant difference between two groups(x2=0.935, P=0.334).4 The Cox multivariate analysis for DFS, OS and clinical pathological indexMultivariate analysis using COX proportional regression hazard model: using the significant variables of single factor analysis statistically(neoadjuvant chemotherapy, operation mode, the diameter of tumor, molecular typing) as independent variables; using the DFS, OS as the dependent variable. Multivariate analysis showed that: surgery mode and tumor subtype are the independent prognostic factor of DFS and OS(P<0.05).Conclusions:1 The Kaplan-Meier for DFS and clinical pathological index shows that surgry, T stage, neoadjuvant chemotherapy and molecular type are the independent factors of DFS in stage IIIC breast cancer patients with internal mammary lymph nodes metastasis(P<0.05).2 The Kaplan-Meier for OS and clinical pathological index shows that surgry, T stage, neoadjuvant chemotherapy and molecular type are also the independent factors of OS in stage IIIC breast cancer patient with internal mammary lymph nodes metastasis(P<0.05).3 The Cox regression hazard model analysis shows that surgery and molecular type are also the most important independent prognostic to the patient’s survival, who is stage IIIC breast cancer with internal mammary lymph nodes metastasis(P<0.05).4 On univariate and multivariate analysis of stage IIIC breast cancer patient with internal mammary lymph nodes metastasis shows that the internal mammary lymph node dissection group’s median DFS and median OS is better than the control group, so the internal mammary lymph node dissection can improve the prognosis of patients to obtain the benefit of survival. |
PDF Full Text Request