Department of Surgery, Maastricht University Medical Centre+, GROW School for Oncology and Reproduction, Maastricht, the Netherlands.
Department of Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands.
Br J Surg. 2024 Mar 2;111(3). doi: 10.1093/bjs/znae071.
In node-positive (cN+) breast cancer treated with neoadjuvant systemic therapy, combining sentinel lymph node biopsy and targeted lymph node excision, that is targeted axillary dissection, increases accuracy. Targeted axillary dissection procedures differ in terms of the targeted lymph node excision technique. This systematic review aimed to provide an overview of targeted axillary dissection procedures regarding definitive marker type and timing of placement: before neoadjuvant systemic therapy (1-step procedure) or after neoadjuvant systemic therapy adjacent to a clip placed before the neoadjuvant therapy (2-step procedure).
PubMed and Embase were searched, to 4 July 2023, for RCTs, cohort studies, and case-control studies with at least 25 patients. Studies of targeted lymph node excision only (without sentinel lymph node biopsy), or where intraoperative localization of the targeted lymph node was not attempted, were excluded. For qualitative synthesis, studies were grouped by definitive marker and timing of placement. The targeted lymph node identification rate was reported. Study quality was assessed using a National Institutes of Health quality assessment tool.
Of 277 unique records, 51 studies with a total of 4512 patients were included. Six definitive markers were identified: wire, 125I-labelled seed, 99mTc, (electro)magnetic/radiofrequency markers, black ink, and a clip. Fifteen studies evaluated one-step procedures, with the identification rate of the targeted lymph node at surgery varying from 8 of 13 to 47 of 47. Forty-one studies evaluated two-step procedures, with the identification rate of the clipped targeted lymph node on imaging after neoadjuvant systemic therapy varying from 49 to 100%, and the identification rate of the targeted lymph node at surgery from 17 of 24 to 100%. Most studies (40 of 51) were rated as being of fair quality.
Various targeted axillary dissection procedures are used in clinical practice. Owing to study heterogeneity, the optimal targeted lymph node excision technique in terms of identification rate and feasibility could not be determined. Two-step procedures are at risk of not identifying the clipped targeted lymph node on imaging after neoadjuvant systemic therapy.
在接受新辅助全身治疗的阳性淋巴结（cN+）乳腺癌患者中，联合前哨淋巴结活检和靶向淋巴结切除（即靶向腋窝解剖）可提高准确性。靶向腋窝解剖程序在靶向淋巴结切除技术方面存在差异。本系统评价旨在提供关于靶向腋窝解剖程序的概述，包括明确的标记物类型和放置时间：新辅助全身治疗前（1 步程序）或新辅助全身治疗后，在新辅助治疗前放置的夹旁边（2 步程序）。
检索了 PubMed 和 Embase，截至 2023 年 7 月 4 日，共纳入了 RCTs、队列研究和病例对照研究，每个研究至少有 25 名患者。排除仅进行靶向淋巴结切除（无前哨淋巴结活检）的研究，或未尝试进行术中靶向淋巴结定位的研究。对于定性综合分析，根据明确的标记物和放置时间对研究进行分组。报告了靶向淋巴结识别率。使用 NIH 质量评估工具评估研究质量。
在 277 条独特的记录中，纳入了 51 项研究，共 4512 名患者。确定了 6 种明确的标记物：金属丝、125I 标记的种子、99mTc、（电磁/射频）标记物、黑墨和夹子。15 项研究评估了 1 步程序，手术时靶向淋巴结的识别率从 13 例中的 8 例到 47 例中的 47 例不等。41 项研究评估了 2 步程序，新辅助全身治疗后靶向淋巴结的夹上成像识别率从 49%到 100%不等，手术时靶向淋巴结的识别率从 24 例中的 17 例到 100%不等。大多数研究（51 项中的 40 项）被评为质量中等。
在临床实践中使用了各种靶向腋窝解剖程序。由于研究的异质性，无法确定在识别率和可行性方面最佳的靶向淋巴结切除技术。两步程序有风险不能识别新辅助全身治疗后靶向淋巴结的夹上成像。
