Park Julia, Fey Jane V, Naik Arpana M, Borgen Patrick I, Van Zee Kimberly J, Cody Hiram S
Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
Ann Surg. 2007 Mar;245(3):462-8. doi: 10.1097/01.sla.0000250439.86020.85.
To compare sentinel lymph node (SLN)-positive breast cancer patients who had completion axillary dissection (ALND) with those who did not, with particular attention to clinicopathologic features, nomogram scores, rates of axillary local recurrence (LR), and changes in treatment pattern over time.
While conventional treatment of SLN-positive patients is to perform ALND, there may be a low-risk subgroup of SLN-positive patients in whom ALND is not required. A multivariate nomogram that predicts the likelihood of residual axillary disease may assist in identifying this group.
Among 1960 consecutive SLN-positive patients (1997-2004), 1673 (85%) had ALND ("SLN+/ALND") and 287 (15%) did not ("SLN+/no ALND"). We compare in detail the clinicopathologic features, nomogram scores, and rates of axillary LR between groups.
Compared with the SLN+/ALND group, patients with SLN+/no ALND were older, had more favorable tumors, were more likely to have breast conservation, had a lower median predicted risk of residual axillary node metastases (9% vs. 37%, P < 0.001), and had a marginally higher rate of axillary LR (2% vs. 0.4%, P = 0.004) at 23 to 30 months' follow-up; half of all axillary LR in SLN+/no ALND patients were coincident with other local or distant sites. For patients in whom intraoperative frozen section was either negative or not done, the rate of completion ALND declined from 79% in 1997 to 62% in 2003 to 2004 but varied widely by surgeon, ranging from 37% to 100%. For 10 of 10 evaluable surgeons, the median nomogram scores in the SLN+/no ALND group were <or=10.5.
SLN+/no ALND breast cancer patients, a selected group with relatively favorable disease characteristics, had a 9% predicted likelihood of residual axillary disease by nomogram but an observed axillary LR of 2%. A gradual and significant decline over time in the rate of completion ALND is associated with, but not entirely explained by, the institution of a predictive nomogram. It is reasonable to omit ALND for a low-risk subset of SLN-positive patients.
比较接受腋窝淋巴结清扫术（ALND）的前哨淋巴结（SLN）阳性乳腺癌患者与未接受该手术的患者，特别关注临床病理特征、列线图评分、腋窝局部复发（LR）率以及治疗模式随时间的变化。
虽然SLN阳性患者的传统治疗方法是进行ALND，但可能存在一部分低风险的SLN阳性患者不需要进行ALND。一个预测腋窝残留疾病可能性的多变量列线图可能有助于识别这一群体。
在1960例连续的SLN阳性患者（1997 - 2004年）中，1673例（85%）接受了ALND（“SLN+/ALND”组），287例（15%）未接受（“SLN+/未行ALND”组）。我们详细比较了两组之间的临床病理特征、列线图评分和腋窝LR率。
与SLN+/ALND组相比，SLN+/未行ALND组的患者年龄更大，肿瘤情况更有利，更有可能接受保乳治疗，腋窝淋巴结残留转移的预测中位风险更低（9%对37%，P < 0.001），在23至30个月的随访中腋窝LR率略高（2%对0.4%，P = 0.004）；SLN+/未行ALND组所有腋窝LR中有一半与其他局部或远处部位的复发同时出现。对于术中冰冻切片为阴性或未进行的患者，完成ALND的比例从1997年的79%下降到2003年至2004年的62%，但因外科医生而异，范围从37%到100%。对于10位可评估的外科医生中的10位，SLN+/未行ALND组的列线图评分中位数≤10.5。
SLN+/未行ALND的乳腺癌患者是一组疾病特征相对较好的特定人群，根据列线图预测腋窝残留疾病的可能性为9%，但观察到的腋窝LR率为2%。随着时间的推移，完成ALND的比例逐渐显著下降，这与预测列线图的应用有关，但不能完全由其解释。对于低风险的SLN阳性患者子集省略ALND是合理的。
