腋窝淋巴结阳性乳腺癌新辅助化疗后腋窝治疗选择的研究
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摘要
目的:分析腋窝淋巴结(axillary lymph node,ALN)阳性乳腺癌患者新辅助化疗(neoadjuvant chemotherapy,NAC)后经前哨淋巴结活检术(sentinel lymph node biopsy,SLNB)评估ALN状态的可行性,并探讨腋窝的后续治疗选择。方法:回顾性分析2016年1月至2018年1月天津医科大学肿瘤医院收治的82例ALN阳性乳腺癌患者的临床资料,均NAC后行SLNB,评估其检出率、准确率、假阴性率(false negative rate,FNR)并对可能影响因素进行分层分析。结果:82例患者腋窝病理完全缓解(pathological com-plete response,pCR)43例、占52.4%,SLNB检出率为97.56%(80/82),准确率为88.75%(71/80),FNR为23.08%(9/39)。前哨淋巴结(sentinel lymph node,SLN)检出数目为1、2枚和数目≥3枚时,FNR分别为20.0%(2/10)、71.4%(5/7)和9.1%(2/22),准确率分别为90.9%(20/22)、66.7%(10/15)和95.3%(41/43),差异具有统计学意义(均P<0.05)。结论:ALN阳性乳腺癌患者NAC后行SLNB总体FNR较高,尚未达到临床可接受范围,不能完全取代腋窝淋巴结清扫(axillary lymph node dissection,ALND),SLN检出数目≥3枚时SLNB可准确评估ALN状态。
Objective: To analyze the feasibility of axillary lymph node staging through sentinel lymph node biopsy(SLNB) after neoadjuvant chemotherapy(NAC) in patients with node-positive breast cancer and to explore the follow-up treatment of these patients.Methods: Clinical data of 82 patients with node-positive breast cancer before NAC in Tianjin Medical University Cancer Institute and Hospital from January 2016 to January 2018 were analyzed retrospectively. All these patients accepted SLNB after NAC. The detection rate, accuracy, false negative rate(FNR), and influencing factors were analyzed. Results: A nodal pathological complete response(PCR)was achieved in 43 of 82 patients. The PCR rate was 52.4%. The detection rate, accuracy, and FNR were 97.56%(80/82), 88.75%(71/80), and 23.08%(9/39), respectively. The accuracy of 1, 2, and ≥3 SLNs detected were 90.9%(20/22), 66.7%(10/15), and 95.3%(41/43), respectively. The FNRs were 20.0%(2/10), 71.4%(5/7), and 9.1%(2/22), respectively(both P<0.05). Conclusions: Due to its overall high FNR, without clinically acceptable limits, post-NAC SLNB cannot completely replace axillary lymph node dissection(ALND) in nodepositive patients. However, with no less than 3 SLNs detected, SLNB can accurately evaluate the status of axillary lymph nodes.
Objective: To analyze the feasibility of axillary lymph node staging through sentinel lymph node biopsy(SLNB) after neoadjuvant chemotherapy(NAC) in patients with node-positive breast cancer and to explore the follow-up treatment of these patients.Methods: Clinical data of 82 patients with node-positive breast cancer before NAC in Tianjin Medical University Cancer Institute and Hospital from January 2016 to January 2018 were analyzed retrospectively. All these patients accepted SLNB after NAC. The detection rate, accuracy, false negative rate(FNR), and influencing factors were analyzed. Results: A nodal pathological complete response(PCR)was achieved in 43 of 82 patients. The PCR rate was 52.4%. The detection rate, accuracy, and FNR were 97.56%(80/82), 88.75%(71/80), and 23.08%(9/39), respectively. The accuracy of 1, 2, and ≥3 SLNs detected were 90.9%(20/22), 66.7%(10/15), and 95.3%(41/43), respectively. The FNRs were 20.0%(2/10), 71.4%(5/7), and 9.1%(2/22), respectively(both P<0.05). Conclusions: Due to its overall high FNR, without clinically acceptable limits, post-NAC SLNB cannot completely replace axillary lymph node dissection(ALND) in nodepositive patients. However, with no less than 3 SLNs detected, SLNB can accurately evaluate the status of axillary lymph nodes.
引文
[1]中国抗癌协会乳腺癌专业委员会.中国抗癌协会乳腺癌诊治指南与规范(2017年版)[J].中国癌症杂志,2017,27(9):695-759.
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[7]Lyman GH,Somerfield MR,Bosserman LD,et al.Sentinel lymph node biopsy for patients with early-stage breast cancer:American society of clinical oncology clinical practice guideline update[J].J Clin Oncol,2017,35(5):561-564.
[8]Yu Y,Cui N,Li HY,et al.Sentinel lymph node biopsy after neoadjuvant chemotherapy for breast cancer:retrospective comparative evaluation of clinically axillary lymph node positive and negative patients,including those with axillary lymph node metastases confirmed by fine needle aspiration[J].BMC Cancer,2016,16(1):808.
[9]Cao XS,Li HJ,Cong BB,et al.Axillary and internal mammary sentinel lymph node biopsy in breast cancer after neoadjuvant chemotherapy[J].Oncotarget,2016,7(45):74074-74081.
[10]Choi HJ,Kim I,Alsharif E,et al.Use of sentinel lymph node biopsy after neoadjuvant chemotherapy in patients with axillary node-positive breast cancer in diagnosis[J].J Breast Cancer,2018,21(4):433-441.
[11]Cabio?lu N,Karanlik H,Kangal D,et al.Improved false-negative rates with intraoperative identification of clipped nodes in patients undergoing sentinel lymph node biopsy after neoadjuvant chemotherapy[J].Ann Surg Oncol,2018,25(10):3030-3036.
[12]Guo J,Yang H,Wang S,et al.Comparison of sentinel lymph node biopsy guided by indocyanine green,blue dye,and their combination in breast cancer patients:a prospective cohort study[J].World J Surg Oncol,2017,15(1):196.
[13]Caudle AS,Yang WT,Krishnamurthy S,et al.Improved axillary evaluation following neoadjuvant therapy for patients with node-positive breast cancer using selective evaluation of clipped nodes:implementation of targeted axillary dissection[J].J Clin Oncol,2016,34(10):1072-1078.
[14]Donker M,Straver ME,Wesseling J,et al.Marking axillary lymph nodes with radioactive iodine seeds for axillary staging after neoadjuvant systemic treatment in breast cancer patients:the MARI procedure[J].Ann Surg,2015,261(2):378-382.
[15]Giuliano AE,Ballman K,Mc Call L,et al.Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases:long-term follow-up from the American college of surgeons oncology group(Alliance)ACOSOG Z0011 randomized trial[J].Ann Surg,2016,264(3):413-420.
[2]Krag DN,Anderson SJ,Julian TB,et al.Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer:overall survival findings from the NSABP B-32 randomised phase 3 trial[J].Lancet Oncol,2010,11(10):927-933.
[3]Galimberti V,Cole BF,Viale G,et al.Axillary dissection versus no axillary dissection in patients with breast cancer and sentinel-node micrometastases(IBCSG 23-01):10-year follow-up of a randomised,controlled phase 3 trial[J].Lancet Oncol,2018,19(10):1385-1393.
[4]Kuehn T,Bauerfeind I,Fehm T,et al.Sentinel-lymph-node biopsy in patients with breast cancer before and after neoadjuvant chemotherapy(SENTINA):a prospective,multicentre cohort study[J].Lancet Oncol,2013,14(7):609-618.
[5]Boughey JC,Suman VJ,Mittendorf EA,et al.Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with nodepositive breast cancer:the ACOSOG Z1071(Alliance)clinical trial[J].JAMA,2013,310(14):1455-1461.
[6]El Hage Chehade H,Headon H,El Tokhy O,et al.Is sentinel lymph node biopsy a viable alternative to complete axillary dissection following neoadjuvant chemotherapy in women with node-positive breast cancer at diagnosis?An updated meta-analysis involving 3,398 patients[J].Am J Surg,2016,212(5):969-981.
[7]Lyman GH,Somerfield MR,Bosserman LD,et al.Sentinel lymph node biopsy for patients with early-stage breast cancer:American society of clinical oncology clinical practice guideline update[J].J Clin Oncol,2017,35(5):561-564.
[8]Yu Y,Cui N,Li HY,et al.Sentinel lymph node biopsy after neoadjuvant chemotherapy for breast cancer:retrospective comparative evaluation of clinically axillary lymph node positive and negative patients,including those with axillary lymph node metastases confirmed by fine needle aspiration[J].BMC Cancer,2016,16(1):808.
[9]Cao XS,Li HJ,Cong BB,et al.Axillary and internal mammary sentinel lymph node biopsy in breast cancer after neoadjuvant chemotherapy[J].Oncotarget,2016,7(45):74074-74081.
[10]Choi HJ,Kim I,Alsharif E,et al.Use of sentinel lymph node biopsy after neoadjuvant chemotherapy in patients with axillary node-positive breast cancer in diagnosis[J].J Breast Cancer,2018,21(4):433-441.
[11]Cabio?lu N,Karanlik H,Kangal D,et al.Improved false-negative rates with intraoperative identification of clipped nodes in patients undergoing sentinel lymph node biopsy after neoadjuvant chemotherapy[J].Ann Surg Oncol,2018,25(10):3030-3036.
[12]Guo J,Yang H,Wang S,et al.Comparison of sentinel lymph node biopsy guided by indocyanine green,blue dye,and their combination in breast cancer patients:a prospective cohort study[J].World J Surg Oncol,2017,15(1):196.
[13]Caudle AS,Yang WT,Krishnamurthy S,et al.Improved axillary evaluation following neoadjuvant therapy for patients with node-positive breast cancer using selective evaluation of clipped nodes:implementation of targeted axillary dissection[J].J Clin Oncol,2016,34(10):1072-1078.
[14]Donker M,Straver ME,Wesseling J,et al.Marking axillary lymph nodes with radioactive iodine seeds for axillary staging after neoadjuvant systemic treatment in breast cancer patients:the MARI procedure[J].Ann Surg,2015,261(2):378-382.
[15]Giuliano AE,Ballman K,Mc Call L,et al.Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases:long-term follow-up from the American college of surgeons oncology group(Alliance)ACOSOG Z0011 randomized trial[J].Ann Surg,2016,264(3):413-420.