Kirurško zdravljenje raka dojk pri starejših od 80 let: koliko je dovolj?

The population of older people is increasing and so is the population of breast cancer patients aged 80 years or older. Unfortunately there is no consensus or recommendations on how to treat older breast cancer patients. The aim of our retrospective study was to identify the most appropriate surgical treatment of breast cancer in patients aged 80 years or older and to determine their survival. We reviewed the medical records of 154 patients with early-stage breast cancer (mean age of 83 years; ranging from 80 to 90 years), who underwent surgery at the Institute of Oncology Ljubljana in the period from 2000 to 2008 when they were aged 80 years or older. We collected data on the extent of the disease, pathomorphology of the tumour, treatment method, extent of breast and axillary lymph node surgery, disease recurrence, cause of death, length of survival, and length of survival for breast cancer. Using univariate and multivariate analyses, we also determined the correlation between prognostic factors, type of treatment and survival. Breast cancer was growth in the breast in 28%, whereas 47% of patients were diagnosed with regional metastases, and the extent of the disease was unknown in 25%. 75% of patients were staged as pT1/pT2, while 25% had stage pT3/pT4 tumours. Surgical treatment comprised: quadrantectomy (in 27%), mastectomy (in 73%), axillary dissection (in 57%), sentinel lymph node biopsy (in 18%), and 25% of patients had no axillary surgery. A total of 88% of patients received adjuvant hormonal treatment (tamoxifen - 53 patients, aromatase inhibitor - 45 patients, a combination of both - 37 patients), while 1.3% of patients were treated with cytostatics, and 16% underwent biopsy. During follow-up of 0.1 to 11 years (median 4.45 years), disease recurrence was observed in 23%. Local recurrence of the disease was observed in 10%, regional recurrence in 6% and distant metastases in 23%. Five-year survival for breast cancer was 90% in locally limited cancer and 62% in regionally advanced cancer. One of the patients died on the first day after surgery due to a myocardial infarction. A total of 19% of all patients died of breast cancer, and 12% died of other causes. The univariate analysis showed that the length of survival of breast cancer patients was correlated with the following factors: treatment with hormones before surgery, pathological T-stage, pathological N-stage, breast surgery, lymph node surgery, oestrogen receptors, degree of tumour differentiation, radicality of surgery, and surgical treatment according to the established guidelines. Using the multivariate statistical analysis, we found that the pathological T-stage, pathological N-stage and oestrogen receptors were independent prognostic factors for the duration of survival of breast cancer patients. The results of our multivariate analysis show that surgeons adjusted the extent of operative treatment according to the stage of the disease and the general condition of the patient. Short survival for breast cancer indicates that, in patients aged 80 years or older, breast cancer with metastases in axillary lymph nodes can be a very aggressive disease.Populacija starejših ljudi se veča, zato se povečuje tudi število bolnic z rakom dojke, ki so starejše od 80 let. Žal ni enotnega mnenja oziroma strokovnih priporočil o tem, kako zdraviti starejše bolnice z rakom dojk. Namen naše retrospektivneštudije je bil ugotoviti, kako kirurško zdravimo raka dojk pri bolnicah, starih 80 let ali več in kakšno je njihovo preživetje.Pregledali smo popise bolezni 154 bolnic z začetnim rakom dojke (povprečna starost 83 let; razpon od 80 do 90 let), ki so bile na Onkološkem inštitutu Ljubljana operirane vobdobju od leta 2000 do leta 2008 in so bile ob operaciji stare 80 let ali več. Zbrali smo podatke o obsegu bolezni, patomorfoloških značilnostih tumorja, načinu zdravljenja,obsegu operacije dojke in pazdušnih bezgavk, ponovitvi bolezni, vzroku smrti, dolžini preživetja in dolžini preživetjaglede raka dojk. Z univariatno in mutivariatno analizo smo ugotavljali povezavo med prognostičnimi dejavniki, vrsto zdravljenja in preživetjem glede raka dojk. Rak dojke je bilomejen na dojko v 28 %, v 47% so bili prisotni regionalni zasevki, obseg bolezni pa ni bil znan v 25 %. Tumorski stadij pT1/pT2 je imelo 75 % bolnic, pT3/pT4 pa je imelo 25 %bolnic. Kirurško zdravljenje je obsegalo: kvadrantektomijov 27 %, mastektomijo v 73 %, izpraznitev pazduhe v 57 %,biopsijo varovalne bezgavke v 18 %, brez posega v pazduho pa je bilo 25 % bolnic. Adjuvantno hormonsko zdravljenje je imelo 88 % bolnic (tamoxifen 53, aromatazni inhibitor 45,kombinacija obeh 37 bolnic), zdravljenje s citostatiki je imelo1,3 % bolnic, obsevanih pa je bilo 16 % bolnic. Ponovitev bolezni smo dokazali v 23 %, v času sledenja od 0,1 do 11 let(mediana 4,45 leta). Lokalno ponovitev bolezni smo dokazali v 10 %, reginalno v 6 % in oddaljene zasevke v 23 %. Petletno preživetje glede raka dojk je bilo pri lokalno omejenem raku 90 %, pri regionalno razširjenem pa 62 %. Ena od bolnicje umrla prvi dan po operativnem posegu zaradi srčnega infarkta. Zaradi raka dojk je umrlo 19 % bolnic, zaradi drugih vzrokov pa 12 % bolnic. Univariatna analiza je pokazala, da so bili z dolžino preživetja zaradi raka dojk povezani naslednji dejavniki: zdravljenje s hormoni pred operacijo, patološki Tstadij, patološki N stadij, operacija dojke, odstranitev vsehpazdušnih bezgavk, operacija bezgavk, estrogenski receptorji,stopnja diferenciacije tumorja, radikalnost kirurškega posega in kirurško zdravljenje v skladu s smernicami. Z multivariatnostatistično analizo smo ugotovili, da so bili patološki T stadij, patološki N stadij in estrogenski receptorji neodvisni prognostični dejavniki za dolžino preživetja zaradi raka dojk. Rezultati naše multivariatne analize kažejo, da so kirurgi ustrezno prilagodili obseg operativnega zdravljenja stadiju bolezni in splošnemu stanju bolnice. Kratko preživetje glede raka dojk je pokazatelj tega, da je rak dojke z zasevki v pazdušnih bezgavkah pri bolnicah, starih 80 let ali več, lahko agresivna bolezen. ; slv - slovensk