Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
Department of Surgical Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA.
Ann Surg Oncol. 2023 Dec;30(13):8371-8380. doi: 10.1245/s10434-023-14029-7. Epub 2023 Aug 23.
Axillary management varies between sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND) for patients with clinical N1 (cN1), hormone receptor-positive (HR+), human epidermal growth factor receptor 2 (HER2)/neu-negative (HER2-), infiltrative ductal carcinoma (IDC) who achieve a complete clinical response (cCR) to neoadjuvant systemic therapy (NAST). This study sought to evaluate clinical practice patterns and survival outcomes of SLNB versus ALND in this patient subset.
Patients with cN1, HR+/HER2-, unilateral IDC demonstrating a cCR to NAST were identified from the 2012-2017 National Cancer Database (NCDB) and stratified based on final axillary surgery management (SLNB vs ALND). After propensity score-matching, overall survival (OS) was compared using a Kaplan-Meier analysis, and significant OS predictors were identified using Cox regression.
Of the 1676 patients selected for this study, 593 (35.4%) underwent SLNB and 1083 (64.6%) underwent ALND. Use of SLNB increased by 28 % between 2012 and 2017. Among a total of 584 matched patients, 461 matched ypN0 patients, and 108 matched ypN+ patients, mean OS did not differ between SLNB and ALND (all patients [92.1 ± 0.8 vs 90.2 ± 1.0 months; p = 0.157], ypN0 patients [92.4 ± 0.8 vs 89.9 ± 0.9 months; p = 0.105], ypN+ patients [83.5 ± 2.3 vs 91.7 ± 2.7 months; p ± 0.963). Cox regression identified age, Charlson score, clinical T stage, and pathologic nodal status as significant predictors of OS.
The final surgical management strategy used for cN1, HR+/HER2- IDC patients who achieved a cCR to NAST did not have a significant impact on survival outcomes in this analysis. Potential opportunities for de-escalation of axillary management among this patient subset exist, and validation studies are needed.
对于临床 N1（cN1）、激素受体阳性（HR+）、人表皮生长因子受体 2（HER2）/neu 阴性（HER2-）、浸润性导管癌（IDC）且新辅助全身治疗（NAST）后获得完全临床缓解（cCR）的患者，腋窝管理方式在前哨淋巴结活检（SLNB）和腋窝淋巴结清扫（ALND）之间有所不同。本研究旨在评估在这一患者亚组中 SLNB 与 ALND 的临床实践模式和生存结局。
从 2012 年至 2017 年国家癌症数据库（NCDB）中确定了临床 N1、HR+/HER2-、单侧 IDC 且对 NAST 获得 cCR 的患者，并根据最终腋窝手术管理方式（SLNB 与 ALND）进行分层。在进行倾向评分匹配后，采用 Kaplan-Meier 分析比较总生存期（OS），并使用 Cox 回归识别显著的 OS 预测因素。
在这项研究中，共有 1676 例患者入选，其中 593 例（35.4%）接受了 SLNB，1083 例（64.6%）接受了 ALND。2012 年至 2017 年间，SLNB 的使用率增加了 28%。在总共 584 例匹配患者中，461 例为 ypN0 患者，108 例为 ypN+患者，SLNB 和 ALND 之间的总生存期无差异（所有患者 [92.1±0.8 与 90.2±1.0 个月；p=0.157]、ypN0 患者 [92.4±0.8 与 89.9±0.9 个月；p=0.105]、ypN+患者 [83.5±2.3 与 91.7±2.7 个月；p=0.963]）。Cox 回归分析确定年龄、Charlson 评分、临床 T 分期和病理淋巴结状态是 OS 的显著预测因素。
在这项分析中，对于获得 NAST 完全临床缓解的 cN1、HR+/HER2-IDC 患者，最终的腋窝手术管理策略对生存结局没有显著影响。在这一患者亚组中，存在降阶腋窝管理的潜在机会，需要验证性研究。
