Angarita Stephanie, Ye Linda, Rünger Dennis, Hadaya Joseph, Baker Jennifer L, Dawson Nicole, Thompson Carlie K, Lee Minna K, Attai Deanna J, DiNome Maggie L
Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
Department of Medicine, Statistics Core, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
Ann Surg Oncol. 2021 May;28(5):2609-2618. doi: 10.1245/s10434-020-09228-5. Epub 2020 Oct 21.
Omission of axillary lymph node dissection (ALND) is accepted for patients with one or two positive sentinel nodes, and studies are focusing on clinically node-positive patients who have been downstaged with neoadjuvant chemotherapy (NAC). Evidence is lacking for patients with positive nodes who undergo surgery upfront. These patients are assumed to have a higher burden of nodal disease such that ALND remains the standard of care.
Patients who underwent ALND for breast cancer between 2010 and 2019 at the authors' institution were retrospectively identified. Those with clinical N1 disease were included in the study. Patients who received NAC and those who had surgery for sentinel node positive disease or axillary recurrence were excluded. Clinical and pathologic factors associated with nodal stage were evaluated.
Of 111 patients who met the inclusion criteria, 61.3% had a palpable node on exam, and 41.4% ultimately had pN1 disease. Most of the tumors were estrogen receptor (ER)-positive (91.5%), and 21.7% of the tumors were invasive lobular cancers. Lobular histology, tumor size, and metastasis size were associated with higher nodal stage. In the multivariable analysis, the patients with nodal metastasis larger than 10 mm had significantly lower odds of having pN1 disease (odds ratio 0.12; 95% confidence interval 0.02-0.69; p = 0.02). In a subset analysis of patients with palpable nodes, tumor size and histology remained significantly associated with nodal stage.
More than 40% of breast cancer patients with clinically positive nodes had minimal nodal disease (pN1) at surgery. Additionally, palpable nodes on exam did not predict higher nodal stage. A subset of patients with clinically positive nodes may be identified who can potentially be spared the morbidity of ALND.
对于前哨淋巴结一或两个阳性的患者，省略腋窝淋巴结清扫术（ALND）已被认可，并且研究主要集中于经新辅助化疗（NAC）降期的临床淋巴结阳性患者。对于 upfront 接受手术的淋巴结阳性患者，目前缺乏相关证据。这些患者被认为具有更高的淋巴结疾病负担，因此 ALND 仍是标准治疗方案。
对 2010 年至 2019 年期间在作者所在机构接受乳腺癌 ALND 的患者进行回顾性识别。纳入临床 N1 期疾病患者。排除接受 NAC 的患者以及因前哨淋巴结阳性疾病或腋窝复发而接受手术的患者。评估与淋巴结分期相关的临床和病理因素。
在 111 例符合纳入标准的患者中，61.3%在检查时有可触及的淋巴结，41.4%最终为 pN1 期疾病。大多数肿瘤为雌激素受体（ER）阳性（91.5%），21.7%的肿瘤为浸润性小叶癌。小叶组织学、肿瘤大小和转移灶大小与更高的淋巴结分期相关。在多变量分析中，淋巴结转移大于 10 mm 的患者发生 pN1 期疾病的几率显著降低（比值比 0.12；95%置信区间 0.02 - 0.69；p = 0.02）。在对有可触及淋巴结患者的亚组分析中，肿瘤大小和组织学仍与淋巴结分期显著相关。
超过 40%临床淋巴结阳性的乳腺癌患者在手术时淋巴结疾病轻微（pN1）。此外，检查时可触及的淋巴结并不能预测更高的淋巴结分期。可以识别出一部分临床淋巴结阳性患者，他们可能无需承受 ALND 的并发症。
