Ebner Florian, Wöckel Achim, Janni Wolfgang, Kreienberg Rolf, Schwentner Lukas, Wischnewsky Manfred
Department of Gynaecology and Obstetrics, University of Ulm, Prittwitzstraße 43, 89075, Ulm, Germany.
Department of Gynaecology and Obstetrics, University of Würzburg, Josef-Schneider-Str. 4, Haus C15, 97080, Würzburg, Germany.
J Cancer Res Clin Oncol. 2017 Sep;143(9):1823-1831. doi: 10.1007/s00432-017-2425-3. Epub 2017 Apr 24.
Sentinel lymph node (SLN) biopsy has replaced axillary lymph node dissection (ALND) for the staging of clinically node-negative breast cancer patients (BCP), demonstrating equivalent survival to ALND while resulting in reduced morbidity. ALND has remained the standard of care for the majority of BCP with clinical axillary metastases or metastases found on SLN biopsy. More recently, it is debated whether ALND could be avoided not only in SLN-negative BCP but also in selected SLN-positive disease or even in all patients. This analysis of pN+ BCP shows the impact of the number of excised lymph nodes on RFS and OAS adjusted by age, tumor size, intrinsic subtypes and adjuvant systemic therapy.
In this retrospective, multicenter cohort study, we investigated data from 2992 pN+ primary BCP recruited from 17 participating certified breast cancer centers in Germany between 2001 and 2008 within the BRENDA study group.
The median number of excised lymph nodes was 17. The number of excised lymph nodes was neither significant for RFS (p = 0.085) nor for OAS (p = 0.285). Adjustments were made for age, tumor size and intrinsic subtypes. The most important significant parameters for RFS were intrinsic subtypes (p < 0.001) and tumor size (p < 0.001) and for OAS age (p < 0.001) and intrinsic subtypes (p < 0.001). There were no significant differences in RFS and OAS in any subgroup stratified by the number of excised lymph nodes. Only for T3/T4 tumors, there is a very small significant advantage of ALND for RFS but not for OAS. After adjusting in addition by guideline adherence of adjuvant systemic therapy (AST), intrinsic subtypes and guideline-adherent AST are the most important significant (p < 0.001) parameters for RFS and OAS.
The number of excised lymph nodes of pN+ BCP neither correlates with RFS nor with OAS. Survival of pN+ BCP is primarily determined by the biology and the guideline-adherent AST based on the corresponding intrinsic subtypes. These results support the omission of a radical ALND at least for pN+ patients scheduled for breast-conserving surgery (not mastectomy), provided they receive whole breast irradiation and guideline-adherent AST.
前哨淋巴结（SLN）活检已取代腋窝淋巴结清扫术（ALND）用于临床腋窝淋巴结阴性乳腺癌患者（BCP）的分期，显示出与ALND相当的生存率，同时降低了发病率。对于大多数有临床腋窝转移或SLN活检发现转移的BCP患者，ALND仍然是标准治疗方法。最近，人们争论是否不仅在SLN阴性的BCP中，而且在选定的SLN阳性疾病甚至所有患者中都可以避免ALND。对pN + BCP的这项分析显示了切除淋巴结数量对经年龄、肿瘤大小、内在亚型和辅助全身治疗调整后的无复发生存期（RFS）和总生存期（OAS）的影响。
在这项回顾性多中心队列研究中，我们调查了2001年至2008年期间在德国17个参与认证的乳腺癌中心招募的2992例pN +原发性BCP患者的数据，这些数据来自BRENDA研究组。
切除淋巴结的中位数为17个。切除淋巴结的数量对RFS（p = 0.085）和OAS（p = 0.285）均无显著影响。对年龄、肿瘤大小和内在亚型进行了调整。RFS最重要的显著参数是内在亚型（p < 0.001）和肿瘤大小（p < 0.001），而OAS的最重要显著参数是年龄（p < 0.001）和内在亚型（p < 0.001）。在按切除淋巴结数量分层的任何亚组中，RFS和OAS均无显著差异。仅对于T3/T4肿瘤，ALND在RFS方面有非常小的显著优势，但在OAS方面没有。在进一步根据辅助全身治疗（AST）的指南依从性进行调整后，内在亚型和符合指南的AST是RFS和OAS最重要的显著（p < 0.001）参数。
pN + BCP切除淋巴结的数量与RFS和OAS均无相关性。pN + BCP的生存主要由生物学特性和基于相应内在亚型的符合指南的AST决定。这些结果支持至少对于计划进行保乳手术（而非乳房切除术）的pN +患者省略根治性ALND，前提是他们接受全乳放疗和符合指南的AST。
