Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, 10065, USA.
Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
Ann Surg Oncol. 2019 Oct;26(10):3269-3274. doi: 10.1245/s10434-019-07536-z. Epub 2019 Jul 24.
The American College of Surgeons Oncology Group (ACOSOG) Z0011 trial demonstrated that axillary lymph node dissection (ALND) may be omitted for women with two or fewer positive sentinel nodes (SLNs) undergoing breast-conservation therapy (BCT). Lobular histology comprises a minority of patients, and applicability to these discohesive cancers has been questioned.
From August 2010 to March 2017, patients undergoing BCT for cT1-2N0 cancer with positive SLNs were prospectively managed with ALND for three or more positive SLNs or gross extracapsular extension (ECE). In this study, clinicopathologic characteristics and nodal burden were compared between pure/mixed invasive lobular cancer (ILC) and invasive ductal cancer (IDC) patients.
Among 813 consecutive patients, 104 (12.8%) had ILC and 709 (87.2%) had IDC. ILC was more often multifocal and low grade, and less frequently had lymphovascular invasion (all p < 0.001). ILC more often had SLN macrometastases (81.7% ILC vs. 69.4% IDC; p = 0.01) and more than 2 mm of ECE (30.8% ILC vs. 19.5% IDC; p = 0.03), but the proportions of cases with three or more positive SLNs were similar in the two groups (14.4% ILC vs. 9.9% IDC; p = 0.2). The ALND procedure was performed for 20 ILC patients (19.2%) compared with 97 IDC patients (13.7%) (p = 0.2). Additional positive nodes were found in 80% of the ILC patients versus 56.7% of the IDC patients (p = 0.09). The ALND and nodal burden rates were similar in the estrogen receptor-positive (ER+) subset analysis. In the multivariable analysis, lobular histology (p = 0.03) and larger tumors (p = 0.03) were associated with additional positive nodes. During a median follow-up period of 42 months, there were no isolated axillary recurrences.
Despite a higher proportion of SLN macrometastases and association with more positive nodes at ALND, lobular histology does not predict the need for ALND. ALND is not indicated on the basis of histology among patients otherwise meeting Z0011 criteria.
美国外科医师学院肿瘤学组（ACOSOG）Z0011 试验表明，对于接受保乳治疗（BCT）且有两个或两个以下阳性前哨淋巴结（SLN）的女性，可省略腋窝淋巴结清扫术（ALND）。小叶状组织学占患者的少数，并且这些离散性癌症的适用性受到质疑。
从 2010 年 8 月至 2017 年 3 月，对接受 BCT 治疗 cT1-2N0 癌症且有阳性 SLN 的患者，前瞻性地管理有三个或更多阳性 SLN 或明显的外囊外扩展（ECE）的患者，行 ALND。在这项研究中，比较了纯/混合浸润性小叶癌（ILC）和浸润性导管癌（IDC）患者的临床病理特征和淋巴结负担。
在 813 例连续患者中，有 104 例（12.8%）为 ILC，709 例（87.2%）为 IDC。ILC 更常为多灶性和低级别，并且较少发生血管淋巴管侵犯（均 p<0.001）。ILC 更常发生 SLN 巨转移（81.7%的 ILC 与 69.4%的 IDC；p=0.01）和超过 2mm 的 ECE（30.8%的 ILC 与 19.5%的 IDC；p=0.03），但两组中三个或更多阳性 SLN 的比例相似（14.4%的 ILC 与 9.9%的 IDC；p=0.2）。与 97 例 IDC 患者（13.7%）相比，仅对 20 例 ILC 患者（19.2%）进行了 ALND 手术（p=0.2）。在 ILC 患者中，有 80%发现了额外的阳性淋巴结，而 IDC 患者中则有 56.7%（p=0.09）。在雌激素受体阳性（ER+）亚组分析中，ALND 和淋巴结受累率相似。在多变量分析中，小叶状组织学（p=0.03）和较大的肿瘤（p=0.03）与额外的阳性淋巴结相关。在中位随访 42 个月期间，没有孤立的腋窝复发。
尽管 SLN 巨转移的比例较高，并且与 ALND 时更多的阳性淋巴结相关，但小叶状组织学并不能预测需要 ALND。在其他符合 Z0011 标准的患者中，不应根据组织学进行 ALND。
