乳腺癌术后接受图像引导放疗患者发生高级别急性放射性皮炎的影响因素及预测模型构建

doi:10.3760/cma.j.cn371439-20251229-00055

摘要/Abstract

摘要：

目的分析预测乳腺癌术后接受图像引导放疗（IGRT）患者发生高级别（Ⅲ级及以上）急性放射性皮炎的影响因素，并构建预测模型。方法选取2023年1月至2025年1月空军军医大学唐都医院455例乳腺癌保乳或改良根治术后接受IGRT致急性放射性皮炎的患者为研究对象。对高级别和低级别（Ⅰ~Ⅱ）急性放射性皮炎患者一般临床资料进行比较。采用多因素logistic回归分析预测发生高级别急性放射性皮炎的独立影响因素。绘制受试者操作特征（ROC）曲线评估各影响因素及其联合对患者发生高级别急性放射性皮炎的预测效能。基于多因素分析结果构建列线图预测模型。采用校准曲线验证发生概率与预测概率的一致性，临床决策曲线分析评价预测模型的临床应用价值。结果 455例乳腺癌术后接受IGRT致急性放射性皮炎患者中，低级别急性放射性皮炎374例，其中Ⅰ级270例、Ⅱ级104例；高级别81例，其中Ⅲ级75例、Ⅳ级6例。高级别、低级别急性放射性皮炎患者体质量指数（BMI）（t=10.23， P<0.001）、吸烟史（χ²=9.69， P=0.002）、糖尿病（χ²=4.52， P=0.034）、铁蛋白水平（t=31.55， P<0.001）、超敏C反应蛋白（hs-CRP）水平（t=32.78， P<0.001）、CD3⁺ T细胞水平（t=46.50， P<0.001）差异均有统计学意义。多因素logistic回归分析显示， BMI（OR=1.52， 95%CI为1.15~2.53， P=0.019）、吸烟史（OR=1.44， 95%CI为1.09~1.98， P=0.024）、糖尿病（OR=1.62， 95%CI为1.26~3.05， P=0.013）、铁蛋白水平（OR=1.78， 95%CI为1.49~3.55， P=0.009）、hs-CRP水平（OR=2.09， 95%CI为1.63~4.46， P<0.001）、CD3⁺ T细胞水平（OR=1.96， 95%CI为1.50~3.83， P=0.004）均是预测乳腺癌术后接受IGRT患者发生高级别急性放射性皮炎的独立影响因素。ROC曲线分析显示， BMI、吸烟史、糖尿病、铁蛋白水平、hs-CRP水平、CD3⁺ T细胞水平单独预测乳腺癌术后接受IGRT患者发生高级别急性放射性皮炎的曲线下面积（AUC）分别为0.69、0.67、0.71、0.73、0.77、0.74，六者联合预测的AUC为0.88，六者联合预测较BMI、吸烟史、糖尿病、铁蛋白水平、hs-CRP水平、CD3⁺ T细胞水平单独预测价值更高（Z=3.42， P=0.001；Z=3.35， P=0.001；Z=3.30， P=0.001；Z=2.00， P=0.025；Z=2.55， P=0.007；Z=2.10， P=0.019）。校准曲线显示，列线图预测模型预测乳腺癌术后接受IGRT患者高级别急性放射性皮炎实际发生概率与预测概率较为一致，一致性指数为0.87（95%CI为0.84~0.89），校准曲线拟合良好（χ²=7.49， P=0.485），表明预测模型的校准度较高。临床决策曲线分析显示，预测模型的辨别能力较好，表明预测模型具有潜在的临床应用价值。结论 BMI、吸烟史、糖尿病、铁蛋白水平、hs-CRP水平、CD3⁺ T细胞水平均是预测乳腺癌术后接受IGRT患者发生高级别急性放射性皮炎的独立影响因素，基于该影响因素构建的列线图预测模型具有一定的临床参考和应用价值。

关键词: 乳腺肿瘤, 放射疗法, 影像引导, 放射性皮炎, 影响因素分析

Abstract:

Objective To analyze and predict the influencing factors for patients with breast cancer who received image guided radiation therapy（IGRT）after surgery developing high-grade（grade Ⅲ and above）acute radiodermatitis， and to construct a prediction model. Methods A total of 455 patients who underwent IGRT for acute radiodermatitis after breast-conserving or modified radical mastectomy at Tangdu Hospital， Air Force Medical University from January 2023 to January 2025 were selected as the research subjects. The general clinical data of the patients with high-grade and low-grade（Ⅰ-Ⅱ）acute radiodermatitis were compared. Multivariate logistic regression analysis was used to identify the independent factors influencing the occurrence of high-grade acute radiodermatitis. The receiver operator characteristic（ROC）curve was drawn to evaluate the predictive performance of the each influencing factor and their combinations for the occurrence of high-grade acute radiodermatitis in patients. A prediction model was constructed based on the results of multivariate analysis. The calibration curve was used to verify the consistency between the occurrence probability and the predicted probability. The clinical decision curve analysis was conducted to assess the clinical application value of the prediction model. Results Among the 455 patients with breast cancer who underwent postoperative IGRT and developed acute radiodermatitis， 374 cases were of low-grade acute radiodermatitis， including 270 cases of grade Ⅰ and 104 cases of grade Ⅱ； 81 cases were of high-grade， including 75 cases of grade Ⅲ and 6 cases of grade Ⅳ. There were statistically significant differences in body mass index（BMI）（t=10.23， P<0.001）， smoking history（χ²=9.69， P=0.002）， diabetes（χ²=4.52， P=0.034）， ferritin level（t=31.55， P<0.001）， high-sensitivity C-reactive protein（hs-CRP）level（t=32.78， P<0.001）， and CD3⁺ T cell level（t=46.50， P<0.001）between the high-grade and low-grade acute radiodermatitis patients. Multivariate logistic regression analysis showed that， BMI（OR=1.52， 95%CI：1.15-2.53， P=0.019）， smoking history（OR=1.44， 95%CI：1.09-1.98， P=0.024）， diabetes（OR=1.62， 95%CI：1.26-3.05， P=0.013）， ferritin level（OR=1.78， 95%CI：1.49-3.55， P=0.009）， hs-CRP level（OR=2.09， 95%CI：1.63-4.46， P<0.001）， and CD3⁺ T cell level（OR=1.96， 95%CI：1.50-3.83， P=0.004）were the independent factors influencing the occurrence of high-grade acute radiodermatitis in the patients undergoing IGRT after breast cancer surgery. The ROC curve analysis showed that， the area under the curve（AUC）for BMI， smoking history， diabetes， ferritin level， hs-CRP level， and CD3⁺ T cell level alone in predicting the occurrence of high-grade acute radiodermatitis in the patients undergoing IGRT after breast cancer surgery were 0.69， 0.67， 0.71， 0.73， 0.77， and 0.74， respectively. The AUC of the combined prediction of these six factors was 0.88， indicating that the combined prediction was more valuable than individual predictions based on BMI， smoking history， diabetes， ferritin level， hs-CRP level， and CD3⁺ T cell level（Z=3.42， P=0.001； Z=3.35， P=0.001； Z=3.30， P=0.001； Z=2.00， P=0.025； Z=2.55， P=0.007； Z=2.10， P=0.019）. The calibration curve showed that the actual occurrence probability of high-grade acute radiodermatitis in patients receiving IGRT after breast cancer surgery predicted by the nomogram prediction model was relatively consistent with the predicted probability， with a consistency index of 0.87（95%CI：0.84-0.89）. The calibration curve fitted well（χ²=7.49， P=0.485）， indicating high calibration accuracy of the model. The clinical decision curve showed that the prediction model exhibited good discriminative ability， indicating its potential clinical application value. Conclusions BMI， smoking history， diabetes， ferritin level， hs-CRP level， and CD3⁺ T cell level are the independent factors influencing the occurrence of high-grade acute radiodermatitis in the patients undergoing IGRT after breast cancer surgery. The nomogram prediction model constructed based on these influencing factors has certain clinical reference and application value.

Key words: Breast neoplasms, Radiotherapy, image-guided, Radiodermatitis, Root cause analysis

苏甲林, 郑瑾, 赵参军, 韩丽君, 张杰, 王丽萍. 乳腺癌术后接受图像引导放疗患者发生高级别急性放射性皮炎的影响因素及预测模型构建[J]. 国际肿瘤学杂志, 2026, 53(6): 339-345.

Su Jialin, Zheng Jin, Zhao Canjun, Han Lijun, Zhang Jie, Wang Liping. Factors influencing the occurrence of high-grade acute radiodermatitis in patients undergoing image guided radiation therapy after breast cancer surgery and the construction of a prediction model[J]. Journal of International Oncology, 2026, 53(6): 339-345.

图/表 7

表1

乳腺癌术后接受IGRT患者致高级别和低级别急性放射性皮炎一般临床资料比较"

一般临床资料	高级别（n=81）	低级别（n=374）	t/χ²值	P值	一般临床资料	高级别（n=81）	低级别（n=374）	t/χ²值	P值
年龄（岁）^a	49.98±9.70	50.43±9.79	-0.38	0.707	铁蛋白水平（μg/L）^a	197.34±21.88	135.37±14.47	31.55	<0.001
BMI^a	30.33±4.39	25.94±3.28	10.23	<0.001	hs-CRP水平（mg/L）^a	6.48±2.03	2.05±0.77	32.78	<0.001
吸烟史^b					CD3⁺ T细胞水平（%）^a	86.34±3.25	68.52±3.10	46.50	<0.001
否	68（83.95）	352（94.12）	9.69	0.002	肿瘤部位^b
是	13（16.05）	22（5.88）	9.69	0.002	左胸	39（48.15）	194（51.87）	0.37	0.543
饮酒史^b					右胸	42（51.85）	180（48.13）	0.37	0.543
否	74（91.36）	330（88.24）	0.65	0.419	肿瘤最大径（cm）^a	3.24±0.98	3.20±0.95	0.34	0.733
是	7（8.64）	44（11.76）	0.65	0.419	肿瘤分期^b
高血压^b					Ⅰ期	25（30.86）	110（29.41）	0.12	0.942
否	54（66.67）	254（67.91）	0.05	0.828	Ⅱ期	36（44.44）	174（46.52）
是	27（33.33）	120（32.09）	0.05	0.828	Ⅲ期	20（24.70）	90（24.07）
糖尿病^b					肿瘤分型^b
否	55（67.90）	295（78.88）	4.52	0.034	激素受体阳性型	63（77.78）	280（74.87）	0.60	0.742
是	26（32.10）	79（21.12）	4.52	0.034	HER2阳性型	12（14.81）	56（14.97）
化疗史^b					三阴性型	6（7.41）	38（10.16）
否	50（61.73）	225（60.16）	0.07	0.794	Ki-67核抗原^a	17.19±3.28	17.04±3.19	0.38	0.703
是	31（38.27）	149（39.84）	0.07	0.794	手术类型^b
内分泌治疗史^b					保乳术	23（28.40）	110（29.41）	0.03	0.855
否	39（48.15）	188（50.27）	0.12	0.730	改良根治术	58（71.60）	264（70.59）	0.03	0.855
是	42（51.85）	186（49.73）	0.12	0.730	切口长度（cm）^a	10.04±2.88	10.11±2.92	-0.20	0.845
靶向治疗史^b					最大照射野面积（cm²）^a	22.34±4.38	22.26±4.29	0.15	0.880
否	71（87.65）	336（89.84）	0.34	0.562	子野数量（个）^a	37.34±5.44	37.14±4.89	0.33	0.744
是	10（12.35）	38（10.16）	0.34	0.562	分次照射时间（min）^a	4.33±1.35	4.20±1.30	0.81	0.418

表1

表2

表3

图1

图2

图3

图4

参考文献 26

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指标	截断值	敏感性（%）	特异性（%）	AUC	95%CI
BMI	27.22	32.86	93.41	0.69	0.67~0.72
吸烟史	-	16.47	96.93	0.67	0.64~0.70
糖尿病	-	72.67	43.15	0.71	0.68~0.75
铁蛋白水平	163.34 μg/L	65.33	64.78	0.73	0.69~0.77
hs-CRP水平	3.70 mg/L	55.34	80.26	0.77	0.73~0.81
CD3⁺ T细胞水平	72.48%	53.16	77.25	0.74	0.71~0.79
六者联合	-	71.28	81.35	0.88	0.85~0.90