Department of Oncology & Radiotherapy, Medical University of Gdańsk, Smoluchowskiego 17, 80-214 Gdańsk, Poland.
Breast Unit, Champalimaud Foundation, Av Brasilia, 1400-038 Lisbon, Portugal; Nova Medical School, Campo dos Mártires da Pátria 130, 1169-056 Lisbon, Portugal.
Cancer Treat Rev. 2021 Dec;101:102297. doi: 10.1016/j.ctrv.2021.102297. Epub 2021 Oct 8.
Introduction of sentinel lymph node biopsy, initially in clinically node-negative and subsequently in patients presenting with involved axilla and downstaged by primary systemic therapy, allowed for significant decrease in morbidity compared to axillary lymph node dissection. Concurrently, regional nodal irradiation was demonstrated to improve outcomes in most node-positive patients. Additionally, over the last decades, introduction of more effective systemic therapies has resulted in improvements not only at distant sites, but also in locoregional control, creating space for de-escalation of locoregional treatments. We discuss the data on de-escalation in axillary surgery and irradiation, both in patients undergoing upfront surgery and primary systemic therapy, with special emphasis on the feasibility of omission of nodal irradiation in patients undergoing primary systemic therapy. In view of the accumulating evidence, omission of axillary irradiation may be considered in clinically node-positive patients converting after primary systemic therapy to pathologically negative nodes on sentinel lymph node biopsy (preferably also with in-breast pCR), presenting with lower initial nodal stage, older age and were treated with breast-conserving surgery followed by whole breast irradiation. Omission of regional nodal irradiation in patients with aggressive tumor phenotypes achieving a pCR is under investigation. In patients undergoing preoperative endocrine therapy the adoption of axillary management strategies utilized in case of upfront surgery seems more suitable than those used in post chemotherapy-based primary systemic therapy setting.
前哨淋巴结活检的引入，最初应用于临床淋巴结阴性的患者，随后应用于腋窝受累且经新辅助全身治疗降期的患者，与腋窝淋巴结清扫相比，显著降低了发病率。同时，区域淋巴结放疗已被证明可以改善大多数淋巴结阳性患者的预后。此外，在过去几十年中，引入更有效的全身治疗方法不仅改善了远处部位的预后，而且改善了局部区域控制，为局部区域治疗的降级创造了空间。我们讨论了在腋部手术和放疗中降级的数据，包括在接受 upfront 手术和新辅助全身治疗的患者中，特别强调了在接受新辅助全身治疗的患者中省略淋巴结放疗的可行性。鉴于积累的证据，在接受新辅助全身治疗后从临床淋巴结阳性转为前哨淋巴结活检病理阴性（最好也伴有乳腺内 pCR）的患者、初始淋巴结分期较低、年龄较大且接受保乳手术联合全乳放疗的患者中，可以考虑省略腋窝放疗。对于达到 pCR 的侵袭性肿瘤表型患者，省略区域淋巴结放疗正在研究中。在接受术前内分泌治疗的患者中，采用 upfront 手术中使用的腋窝管理策略似乎比化疗后新辅助全身治疗中使用的策略更合适。
