Breast Surgery Unit, San Raffaele Hospital, Milan, Italy; Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy.
Breast Surgery Unit, San Raffaele Hospital, Milan, Italy.
Eur J Surg Oncol. 2019 Jun;45(6):969-975. doi: 10.1016/j.ejso.2019.01.219. Epub 2019 Jan 31.
The management of axilla after Primary Systemic Therapy (PST) for breast cancer is a highly debated field. Despite the proven axillary downstaging occurring after PST, there is still some degree of reluctance in applying sentinel node biopsy (SNB) in the neoadjuvant setting.
We performed a retrospective analysis on 181 PST patients with axillary positive nodes at presentation treated between 2005 and 2017 at San Raffaele Hospital in Milan. The aim was to observe the application time trend of SNB, to determine the imaging staging power and the axillary downstaging according to molecular subtypes.
Median follow-up after surgery was 32.5(IQR: 12-59) months. After PST, 119 (65.7%) patients had no clinically palpable nodes, 72 (39.7%) converted to N0 on final imaging and 34 (18.8%) underwent SNB with an increasing application trend. Axillary-US showed the highest accuracy (69.3%) in re-staging axilla after PST. Staging power of preoperative testing varied with tumour biology: Positive Predictive Value was higher in Luminal A (80% for clinical examination and 100% for axillary-US) and Luminal B (72% and 70.5%) tumours, whilst Negative Predictive Value was higher in HER2 positive (100% and 93.3%), and triple negative (71.4% and 93.3%) tumours. Ninety five (52.5%) patients experienced axillary downstaging after PST, by molecular subtype 15% (3/20) in Luminal A, 46.4% (45/97) in Luminal B, 90.9% (20/22) in HER2+ and 70.3% (26/37) in triple negative breast tumours.
SNB application after PST for breast cancer in node positive patients at presentation is increasing. Pre-operative axillary imaging and tumour biology help identify patients who might be candidates for SNB as a single staging procedure.
乳腺癌初次全身治疗（PST）后腋窝的管理是一个备受争议的领域。尽管 PST 后腋窝降期已被证实，但在新辅助治疗中应用前哨淋巴结活检（SNB）仍存在一定程度的抵触。
我们对米兰圣拉斐尔医院 2005 年至 2017 年间治疗的 181 例就诊时腋窝阳性淋巴结的 PST 患者进行了回顾性分析。目的是观察 SNB 的应用时间趋势，根据分子亚型确定影像学分期能力和腋窝降期。
术后中位随访时间为 32.5（IQR：12-59）个月。PST 后，119 例（65.7%）患者无临床可触及的淋巴结，72 例（39.7%）最终影像学检查转为 N0，34 例（18.8%）接受 SNB，应用呈上升趋势。腋窝-US 在 PST 后重新分期腋窝方面具有最高的准确性（69.3%）。术前检查的分期能力随肿瘤生物学而变化：临床检查和腋窝-US 的 Luminal A 肿瘤阳性预测值分别为 80%和 100%，Luminal B 肿瘤分别为 72%和 70.5%，而 HER2 阳性肿瘤的阴性预测值分别为 100%和 93.3%，三阴性肿瘤分别为 71.4%和 93.3%。95 例（52.5%）患者在 PST 后出现腋窝降期，按分子亚型 Luminal A 为 15%（3/20），Luminal B 为 46.4%（45/97），HER2+为 90.9%（20/22），三阴性乳腺癌为 70.3%（26/37）。
就诊时腋窝阳性的乳腺癌患者在 PST 后 SNB 的应用呈上升趋势。术前腋窝影像学检查和肿瘤生物学有助于确定可能适合 SNB 作为单一分期手术的患者。
