Postlewait Lauren M, Teshome Mediget, DeSnyder Sarah M, Lim Bora, Kuerer Henry M, Bedrosian Isabelle, Woodward Wendy A, Ueno Naoto T, Lucci Anthony
Division of Surgery, Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
Ann Surg Oncol. 2020 Nov;27(12):4603-4612. doi: 10.1245/s10434-020-08891-y. Epub 2020 Jul 24.
Modified radical mastectomy (MRM), which includes axillary dissection, is the standard of care for inflammatory breast cancer (IBC). While more limited axillary staging after neoadjuvant chemotherapy (NAC) in clinically node-positive non-IBC has been increasingly adopted, the impact of these techniques in IBC is not clear. To inform patient selection for further study of limited axillary surgery, we aimed to describe the frequency and factors associated with pathological node-negativity (ypN0) in IBC.
Patients with IBC who received NAC and MRM were identified from a prospective institutional database (2004-2019). Binary logistic regression analyses were conducted to identify factors associated with ypN0.
Of 453 patients, 189 (41.7%) had a post-NAC clinical nodal stage (ycN stage) of N0 (ycN1: 150, 33.1%; ycN2: 4, 0.9%; ycN3: 47, 10.4%; unknown: 63, 13.9%); 156 (34%) were ypN0. On multivariable analysis, higher tumor grade was not associated with ypN0 (odds ratio [OR] 1.59, 95% confidence interval [CI] 0.90-2.81, p =0.11). Compared with hormone receptor (HR)-negative/human epidermal growth factor receptor 2 (HER2)-negative tumors (n =113, 24.9%), HR-positive/HER2-negative tumors (n =169, 37.3%) had a trend toward less ypN0 (OR 0.55, 95% CI 0.29-1.02, p =0.06); HR-positive/HER2-positive tumors (n =79, 17.4%) were similar to HR-negative/HER2-negative tumors (OR 0.72, 95% CI 0.35-1.48, p =0.37); and HR-negative/HER2-positive tumors (n =92, 20.3%) were associated with increased ypN0 (OR 4.82, 95% CI 2.41-9.63, p <0.001). As ycN stage increased, the likelihood of ypN0 decreased compared with ycN0 patients (ycN1/2: OR 0.54, 95% CI 0.32-0.89, p =0.02; ycN3: OR 0.29, 95% CI 0.13-0.67, p =0.004).
One-third of patients with IBC who received NAC and MRM had pathologically negative nodes. Factors associated with ypN0 included ycN0 status and HR-negative/HER2-positive subtype. Large, prospective studies are needed to investigate the feasibility of alternative nodal evaluation strategies in IBC, with consideration to these subgroups.
改良根治性乳房切除术（MRM），包括腋窝淋巴结清扫，是炎性乳腺癌（IBC）的标准治疗方法。虽然临床上淋巴结阳性的非IBC患者在新辅助化疗（NAC）后采用更有限的腋窝分期方法越来越普遍，但这些技术对IBC的影响尚不清楚。为了指导患者选择以进一步研究有限腋窝手术，我们旨在描述IBC中病理淋巴结阴性（ypN0）的频率及相关因素。
从一个前瞻性机构数据库（2004 - 2019年）中识别出接受NAC和MRM的IBC患者。进行二元逻辑回归分析以确定与ypN0相关的因素。
在453例患者中，189例（41.7%）NAC后的临床淋巴结分期（ycN分期）为N0（ycN1：150例，33.1%；ycN2：4例，0.9%；ycN3：47例，10.4%；未知：63例，13.9%）；156例（34%）为ypN0。多变量分析显示，较高的肿瘤分级与ypN0无关（比值比[OR]1.59，95%置信区间[CI]0.90 - 2.81，p = 0.11）。与激素受体（HR）阴性/人表皮生长因子受体2（HER2）阴性肿瘤（n = 113例，24.9%）相比，HR阳性/HER2阴性肿瘤（n = 169例，37.3%）有ypN0的趋势较小（OR 0.55，95% CI 0.29 - 1.02，p = 0.06）；HR阳性/HER2阳性肿瘤（n = 79例，17.4%）与HR阴性/HER2阴性肿瘤相似（OR 0.72，95% CI 0.35 - 1.48，p = 0.37）；HR阴性/HER2阳性肿瘤（n = 92例，20.3%）与ypN0增加相关（OR 4.82，95% CI 2.41 - 9.63，p < 0.001）。随着ycN分期增加，与ycN0患者相比，ypN0的可能性降低（ycN1/2：OR 0.54，95% CI 0.32 - 0.89，p = 0.02；ycN3：OR 0.29，95% CI 0.13 - 0.67，p = 0.004）。
接受NAC和MRM的IBC患者中有三分之一病理淋巴结为阴性。与ypN0相关的因素包括ycN0状态和HR阴性/HER2阳性亚型。需要进行大型前瞻性研究，考虑这些亚组情况，以调查IBC中替代淋巴结评估策略的可行性。
