Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
Department of Radiation Oncology and Siteman Cancer Center, Washington University School of Medicine, St Louis, MO, USA.
Ann Surg Oncol. 2021 Oct;28(10):5568-5579. doi: 10.1245/s10434-021-10441-z. Epub 2021 Jul 10.
Management of axillary lymph nodes in breast cancer has undergone significant change over the past decade through landmark clinical trials. This study aimed to assess national practice patterns in axillary management in patients undergoing upfront mastectomy and examines what guides provider recommendations.
A national case-based survey study was performed of surgeons and radiation oncologists from July to August 2020. Surgeons were identified through the American Society of Breast Surgeons (ASBrS) after review and approval by the ASBrS Research Committee, and radiation oncologists were identified through an institutional database. Both descriptive and comparative statistical analyses were performed.
Overall, 994 providers responded-680 surgeons and 314 radiation oncologists. Surgeons were older and in practice longer (p < 0.05) and treated a higher percentage of breast patients (81% vs. 40%, p < 0.001). Most surgeons were hospital-employed (43%), whereas most radiation oncologists were in private practice (40%; p < 0.001). Fifty-two percent of surgeons routinely send sentinel lymph nodes (SLNs) for frozen section (52%) during mastectomy, of which 78% proceed directly to axillary lymph node dissection (ALND) if positive. There was significant variability in treatment recommendations between the two groups among the hypothetical cases (p < 0.001). In the setting of low disease burden in the SLNs, > 30% of surgeons recommended ALND, while radiation oncologists recommend axillary radiotherapy over axillary clearance (p < 0.001).
There is significant heterogeneity in the management of the axilla in mastectomy patients with pathologically positive SLNs, both between and among surgeons and radiation oncologists. Efforts should be made to assist both groups in identifying de-escalation opportunities to ensure that mastectomy patients with positive SLNs are treated appropriately.
在过去的十年中，通过具有里程碑意义的临床试验，乳腺癌腋窝淋巴结的管理发生了重大变化。本研究旨在评估在接受 upfront 乳房切除术的患者中腋窝管理的国家实践模式，并研究指导提供者建议的因素。
2020 年 7 月至 8 月，对外科医生和放射肿瘤学家进行了一项基于病例的全国性调查研究。外科医生是通过美国乳腺外科学会（ASBrS）确定的，该学会在 ASBrS 研究委员会审查和批准后进行了识别，而放射肿瘤学家则是通过机构数据库确定的。进行了描述性和比较性统计分析。
共有 994 名提供者做出了回应，其中 680 名外科医生和 314 名放射肿瘤学家。外科医生年龄更大，从业时间更长（p<0.05），治疗的乳腺患者比例更高（81%对 40%，p<0.001）。大多数外科医生是医院雇佣的（43%），而大多数放射肿瘤学家是私人执业的（40%；p<0.001）。52%的外科医生在乳房切除术期间常规发送前哨淋巴结（SLNs）进行冷冻切片（52%），其中如果阳性，则 78%直接进行腋窝淋巴结清扫术（ALND）。在假设病例中，两组之间的治疗建议存在显著差异（p<0.001）。在 SLNs 中疾病负担较低的情况下，超过 30%的外科医生建议进行 ALND，而放射肿瘤学家建议进行腋窝放疗而不是腋窝清除术（p<0.001）。
在 SLNs 病理阳性的乳房切除术患者中，外科医生和放射肿瘤学家之间以及两者之间，腋窝的处理方式存在显著的异质性。应努力帮助这两个群体确定降级机会，以确保 SLNs 阳性的乳房切除术患者得到适当的治疗。
