Almahariq Muayad F, Levitin Ronald, Quinn Thomas J, Chen Peter Y, Dekhne Nayana, Kiran Sayee, Desai Amita, Benitez Pamela, Jawad Maha S, Gustafson Gregory S, Dilworth Joshua T
Department of Radiation Oncology, Beaumont Health, Royal Oak, MI, USA.
Department of Surgery, Beaumont Health, Royal Oak, MI, USA.
Ann Surg Oncol. 2021 Feb;28(2):930-940. doi: 10.1245/s10434-020-08928-2. Epub 2020 Jul 25.
The appropriateness of substituting sentinel lymph node dissection (SLND) and regional nodal irradiation (RNI) for axillary lymph node dissection (ALND) in patients with residual lymph node (LN) disease following neoadjuvant chemotherapy (NAC) is unknown. We used the National Cancer Database (NCDB) to compare survival following SLND and ALND in breast cancer patients with residual LN disease.
We analyzed NCDB patients, treated between 2006 and 2014, with cT1-3, cN1, cM0 breast cancer and residual disease in 1-3 axillary LNs (ypN1) following NAC. Patients were grouped into those who received SLND (defined as removal of ≤ 4 LNs) and RNI, or ALND and RNI. Patients were matched for all patient, tumor, and treatment characteristics.
We identified 1313 eligible patients in the ALND group and 304 patients in the SLND group. For the matched cohorts, SLND was associated with significantly lower survival in both univariate and doubly robust multivariable analyses (MVA) (HR 1.7, 95% CI 1.3-2.2, P < 0.001 for MVA), with estimated 5-year OS of 71%, compared with 77% in the ALND group (P = 0.01). Exploratory subgroup analyses showed that SLND was comparable with ALND in patients with luminal A or B tumors with a single metastatic LN (HR 1.03, 95% CI 0.59-1.8, (P = 0.91).
Our analysis suggests that, while an ALND may not be needed for patients with limited residual nodal burden and biologically favorable tumors, SLND should not be routinely substituted for ALND in patients with ypN1 disease following NAC until its efficacy is confirmed by prospective trials.
新辅助化疗（NAC）后有残留淋巴结（LN）疾病的患者，用前哨淋巴结清扫术（SLND）和区域淋巴结照射（RNI）替代腋窝淋巴结清扫术（ALND）是否合适尚不清楚。我们利用国家癌症数据库（NCDB）比较了有残留LN疾病的乳腺癌患者SLND和ALND后的生存率。
我们分析了2006年至2014年间接受治疗的NCDB患者，这些患者患有cT1-3、cN1、cM0乳腺癌，且NAC后腋窝1-3个LN有残留疾病（ypN1）。患者被分为接受SLND（定义为切除≤4个LN）和RNI的患者，或接受ALND和RNI的患者。对所有患者、肿瘤和治疗特征进行匹配。
我们在ALND组中确定了1313例符合条件的患者，在SLND组中确定了304例患者。对于匹配队列，在单变量和双重稳健多变量分析（MVA）中，SLND均与显著较低的生存率相关（HR 1.7，95%CI 1.3-2.2，MVA的P<0.001），估计5年总生存率为71%，而ALND组为77%（P=0.01）。探索性亚组分析显示，在有单个转移LN的luminal A或B肿瘤患者中，SLND与ALND相当（HR 1.03，95%CI 0.59-1.8，（P=0.91）。
我们的分析表明，虽然残留淋巴结负担有限且生物学行为良好的肿瘤患者可能不需要进行ALND，但在NAC后有ypN1疾病的患者中，在其疗效经前瞻性试验证实之前，不应常规用SLND替代ALND。
