Biolchini Federico, Vicentini Massimo, Di Felice Enza, Giovanardi Filippo, Antonio Lucchini, Giorgi Rossi Paolo, Annessi Valerio
1 Struttura Operativa Complessa di Chirurgia Generale, Ospedale di Guastalla, Reggio Emilia local health center, Reggio Emilia - Italy.
Tumori. 2015 May-Jun;101(3):298-305. doi: 10.5301/tj.5000281. Epub 2015 Apr 2.
Clinical guidelines recommend axillary lymph node dissection (ALND) in cases of metastatic sentinel lymph node (SNL) in patients with clinically node-negative early breast cancer. However, a relevant number of ALND could be avoided in a subset of patients in whom the risk of non-SNL metastases is low. In order to define this population, several authors have proposed mathematical models, which have been validated in many studies. These studies reached different conclusions regarding which model demonstrated the best statistical discrimination power, mainly due to differences in clinical and pathologic variables used, and particularly differences in the number of dissected SLNs.
We retrospectively reviewed clinically node-negative patients who underwent ALND in our surgical ward after the diagnosis of breast cancer metastases on SLN biopsy from January 2000 to December 2012. The predictive accuracy of the widely used nomograms to predict the risk of additional nodal disease in our patients with SLN breast cancer metastases was measured by receiver operating characteristic curve. We then attempted to develop a new nomogram by analyzing the dataset.
A total of 105 patients were included in this study, with ratio of metastatic lymph node/removed lymph node of about 0.89; we found axillary nodal metastases on ALND in only 31 patients (29.5%). Applied to our dataset, Mayo nomogram showed the best area under the receiving operator characteristic curve (0.74) followed by our model (0.71). Instead, the Memorial Sloan-Kettering model showed poor discrimination, as did Tenon (0.56).
Based on our data, we cannot recommend the clinical use of validated predictive nomograms in order to avoid ALND. We suggest setting up a multicenter Italian study to build a model specific to our setting and based on larger series.
临床指南建议，对于临床淋巴结阴性的早期乳腺癌患者，若前哨淋巴结（SNL）发生转移，则应进行腋窝淋巴结清扫（ALND）。然而，在一部分非前哨淋巴结转移风险较低的患者中，可以避免进行ALND。为了明确这一人群，一些作者提出了数学模型，这些模型已在许多研究中得到验证。这些研究对于哪种模型具有最佳的统计判别能力得出了不同结论，这主要是由于所使用的临床和病理变量存在差异，尤其是所清扫的前哨淋巴结数量不同。
我们回顾性分析了2000年1月至2012年12月期间在我们外科病房经前哨淋巴结活检诊断为乳腺癌转移后接受ALND的临床淋巴结阴性患者。通过受试者工作特征曲线来衡量广泛使用的列线图预测我们的前哨淋巴结乳腺癌转移患者发生额外淋巴结疾病风险的预测准确性。然后，我们试图通过分析数据集来开发一种新的列线图。
本研究共纳入105例患者，转移淋巴结/切除淋巴结的比例约为0.89；我们仅在31例患者（29.5%）的ALND中发现腋窝淋巴结转移。应用于我们的数据集时，梅奥列线图在受试者工作特征曲线下的面积最大（0.74），其次是我们的模型（0.71）。相反，纪念斯隆凯特琳模型以及特农模型的判别能力较差（0.56）。
根据我们的数据，我们不建议为避免进行ALND而在临床中使用经过验证的预测列线图。我们建议开展一项意大利多中心研究，以建立一个针对我们的情况且基于更大样本量的模型。
