Department of Surgery, Foothills Medical Centre, University of Calgary, Calgary, AB.
Department of Surgery, BC Cancer, University of British Columbia.
Curr Oncol. 2020 Oct;27(5):250-256. doi: 10.3747/co.27.6515. Epub 2020 Oct 1.
In response to Choosing Wisely recommendations that sentinel lymph node biopsy (slnb) should not be routinely performed in elderly patients with node-negative (cN0), estrogen receptor-positive (er+) breast cancer, we sought to evaluate how nodal staging affects adjuvant treatment in this population.
From a prospective database, we identified patients 70 or more years of age with cN0 breast cancer treated with surgery for er+ her2-negative invasive disease during 2012-2016. We determined rates of, and factors associated with, nodal positivity (pN+), and compared the use of adjuvant radiation (rt) and systemic therapy by nodal status.
Of 364 patients who met the inclusion criteria, 331 (91%) underwent slnb, with 75 (23%) being pN+. Axillary node dissection was performed in 11 patients (3%). On multivariate analysis, tumour size was the only factor associated with pN+ ( = 0.007). Nodal positivity rates were 0%, 13%, 23%, 33%, and 27% for lesions preoperatively sized at 0-0.5 cm, 0.5-1 cm, 1.1-2.0 cm, 2.1-5.0 cm, and more than 5.0 cm. Compared with patients assessed as node-negative, those who were pN+ were more likely to receive axillary rt (lumpectomy: 53% vs. 1%, < 0.001; mastectomy: 43% vs. 2%, < 0.001), and adjuvant systemic therapy (endocrine: 82% vs. 69%; chemotherapy plus endocrine: 7% vs. 2%, = 0.002).
Of elderly patients with cN0 er+ breast cancer, 23% were pN+ on slnb. Size was the primary predictor of nodal status, and yet significant rates of nodal positivity were observed even in tumours preoperatively sized at 1 cm or less. The use of rt and systemic adjuvant therapies differed by nodal status, although the long-term oncologic implications require further investigation. Multidisciplinary input on a case-by-case basis should be considered before omission of slnb.
为了响应选择明智的建议，即在前哨淋巴结活检（SLNB）不应该常规用于淋巴结阴性（cN0）、雌激素受体阳性（ER+）的老年乳腺癌患者，我们试图评估在这一人群中，淋巴结分期如何影响辅助治疗。
从一个前瞻性数据库中，我们确定了 2012 年至 2016 年间，70 岁或以上接受手术治疗 ER+HER2 阴性浸润性疾病且 cN0 乳腺癌的患者。我们确定了淋巴结阳性（pN+）的发生率和相关因素，并比较了淋巴结状态对辅助放疗（RT）和全身治疗的影响。
在符合纳入标准的 364 名患者中，331 名（91%）接受了 SLNB，其中 75 名（23%）为 pN+。11 名患者（3%）行腋窝淋巴结清扫术。多变量分析显示，肿瘤大小是唯一与 pN+相关的因素（=0.007）。术前大小为 0-0.5cm、0.5-1cm、1.1-2.0cm、2.1-5.0cm 和大于 5.0cm 的病变，淋巴结阳性率分别为 0%、13%、23%、33%和 27%。与淋巴结阴性患者相比，pN+患者更有可能接受腋窝 RT（保乳术：53% vs. 1%，<0.001；乳房切除术：43% vs. 2%，<0.001）和辅助全身治疗（内分泌治疗：82% vs. 69%；化疗联合内分泌治疗：7% vs. 2%，=0.002）。
在 cN0 ER+乳腺癌的老年患者中，23%的患者在 SLNB 中出现 pN+。大小是淋巴结状态的主要预测因素，但即使术前肿瘤大小为 1cm 或更小，仍有相当大的淋巴结阳性率。RT 和全身辅助治疗的使用因淋巴结状态而异，尽管长期肿瘤学意义仍需要进一步研究。在考虑省略 SLNB 之前，应根据具体情况由多学科团队进行输入。
