RISK FACTORS FOR BREAST CANCER RECURRENCE : ABOUT 310 CASES

Purpose : To retrospectively study our risk factors for breast cancer recurrence and compare them with data from the literature. Materials and Methods : Through the analysis of 310 patients we identified local, locoregional and / or systemic recurrence factors. Results : The mean age was 49.15 ± 10.37 years, the mean parity was 3.3 ± 2, 43.5% were postmenopausal, 18.3% had a family history of breast cancer, and 41.3% used oral contraception. According to the study of different risk factors for breast cancer recurrence.

All patients underwent surgery (breast surgery + axillary dissection). The surgical margins were negatives in 301 (98.7%) patients. The average number of lymph nodes (LN) removed was 15 ± 5.5. Lymph node dissection was negative in 116 (39.6%) patients, whereas node involvement of more than 4 lymph nodes (> or = 4N +) was noted in 84 (28.5%) patients, and less than 4 (<4N +) lymph nodes, in 95 (32.2%) patients. The results of our analytical study of various risk factors for recurrence are reported in Tables 2 and 3. The univariate analysis (Table 2) indicated that the presence of LVI, lymph node involvement ≥4 and negative HR were statistically significant parameters influencing the occurrence of relapse in our serie. Moreover, multivariate analysis (Table 3) showed that absence of LVI and positive HR were associated with a lower risk of recurrence.

Discussion:-
Through this study, we tried to highlight the risk factors that seemed to influence local, locoregional and metastatic recurrence in our department. We noted that our relapse rate was a little higher than reported in the literature (15.5% versus 8 to 9%) [4,5]. We found a many common risk factors with those found in the literature,such as massive node invasion, the presence of LVI and the HR status. But other decisive factors do not emerge from our analysis.
Massive axillary lymph node involvement is often found as a risk factor for locoregional recurrence [6][7][8][9]. When the axillary or supraclavicular lymph nodes are invaded, the risk of relapse is greater than when the disease is localized to the breast. The risk increases with the number of lymph nodes affected. The absolute number of invading axillary lymph nodes is considered the most important prognostic factor in breast cancer. An accurate assessment of the axillary region is the basis of adjuvant treatment decision and prognostic assessment. Over the past decade, several studies have been published indicating that LNR (Lymph Node Ratio) may be a superior indicator of axillary tumor invasion and predict the outcome better than the number of positive LN. In the Van der Waal study [10], the 10-year survival of patients with LNR greater than or equal to 0.2 was 52%, compared to 73% of patients with LNR less than 0.2 (p = 0.0001). In the Kim.J study [11], the prognostic value of the LNR was evaluated in 144 patients, 130 of whom had a low LNR (0.01-0.15), and 14 patients had a high LNR (> 0.15). The 5-year survival was 93.5% and 85.7% in the patients with low and high LNR respectively. A high LNR was associated with a poor prognosis in the univariate analysis (p <0.004) and the multivariate analysis (OR = 3.453 [1.273-9.361], p <0.015). The results of our work are consistent with these studies since LN involvement was a statistically significant factor of relapse, with OR = 0.420 [0.197-0.896] and p <0.025 for <4N+ and OR = 0.223 [0.097-0.513] and p <0.0004 for ≥4N+ invasion.
The presence of LVI is also found to be a risk factor for locoregional recurrence by many authors [7,[12][13][14][15][16]. This factor is particularly important in patients without lymph node involvement. It is reasonable to assume that the worst prognosis of LVI is related to the high level of tumor cell dissemination (metastasis). Young Du Song [17] demonstrated, through a retrospective study of 967 patients, that lymphovascular invasion (LVI) was a significant independent prognostic factor of disease-free survival (DFS) and overall survival (OS). In univariate analysis, 5-year OS and 5-year DFS were significantly different in patients with and without LVI: 88.8% vs. 94.1% (p = 0.007) for OS and 76.4% % vs. 90.9% (p <0.001) for DFS. In addition, survival without metastasis at 5 years was shorter in patients with LVI: 80.1% versus 91.5% compared to patients without LVI (p <0.001). In our serie, the presence of LVI had a significant effect on relapse with OR = 0.343 [0.17-0.66] and p <0.001. This factor is noted in 66% of patients who had a recurrence.
The value of HR status for predicting the hormone sensitivity of tumors is no longer in doubt. On the other hand, their independent predictive value of relapse is variously appreciated in the literature. Patients with triple-negative breast cancer have an increased likelihood of distant recurrence and death compared to other profiles, and the difference persists after control with established prognostic factors. However, the recurrence patterns in both subgroups are qualitatively different. Patients with triple-negative breast cancer had high recurrence rates only 1 to 4 years after diagnosis. The risk then decreased rapidly and no recurrence occurred after 8 years of follow-up. In the other group, the risk of recurrence and death was stable and continued for 17 years after diagnosis [18]. The presence of hormone receptors was a significant factor in the multivariate analysis in our serie. The odds ratio was OR = 2.525 [1.223-5.217], and p <0.012. Only 28 patients with positive hormone receptor relapses, compared to 199 without local or systemic recurrence.

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The age of patient, the histological SBR grading, the size of the tumor and the quality of margins are often associated with the risk of locoregional and distant recurrence according to several authors [19][20][21][22]. But, our numbers did not allow us to highlight this difference. Thus, all these factors were not identified in the univariate and multivariate analysis of our study.

Conclusion:-
In total, the analysis of the risk factors of 310 breast cancer cases treated in the Mohamed V Military Teaching Hospital in Rabat, highlights known risk factors consistent with the data from the literature; such as; massive node invasion, presence of LVI and HR status. These factors are well used in the various current algorithms of adjuvant treatment decision in order to build a better therapeutic strategy of breast cancer management more and more targeted.
Ethics approval and consent to participate:-Informed consent (verbal) was obtained from all participants. This study was submitted to and approved by research and ethics committee of military teaching hospital Mohamed V