Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.
Research Institute, NorthShore University Health System, Evanston, IL, USA.
Ann Surg Oncol. 2024 Oct;31(11):7498-7507. doi: 10.1245/s10434-024-15703-0. Epub 2024 Jul 8.
Routine sentinel lymphadenectomy (SLNB) for early-stage HR+/HER2- breast cancer in women ≥70 is discouraged by Choosing Wisely, but whether SLNB can be routinely omitted in women ≥70 with DCIS undergoing mastectomy is unclear. This study aims to evaluate rates of axillary surgery and nodal positivity (pN+) in this population to determine the impact of axillary surgery on treatment decisions.
Females ≥70 with DCIS undergoing mastectomy were identified from the National Cancer Database (2012-2020). The rate of upstaging to invasive cancer (≥pT1) or pN+ was assessed. Subset analyses were conducted for ER+ patients. Adjuvant therapies were evaluated among ≥pT1 patients after stratifying by nodal status.
Of 9,030 patients, 1,896 (21%) upstaged to ≥pT1. Axillary surgery was performed in 86% of patients, predominantly sentinel lymphadenectomy (SLNB, 65%). Post hoc application of Choosing Wisely criteria demonstrated that 93% of the entire cohort and 97% of ER+ DCIS patients could have avoided axillary surgery. Nodal positivity was 0.3% among those who didn't upstage, and 12% among those upstaging to ≥pT1, with <2% having pN2-3 disease, irrespective of receptor subtype. Node-positive patients had higher adjuvant therapy usage, but there was no recommendation for adjuvant chemotherapy or radiation for 71% and 66% of pN+ patients, respectively.
Axillary surgery can be omitted for most patients ≥70 undergoing mastectomy for ER+ DCIS, aligning with recommendations for invasive cancer, and omission can be considered in those with ER- disease. Future guidelines incorporating preoperative imaging, as in the SOUND trial, may aid in identifying patients benefiting from axillary surgery.
选择明智建议不常规进行 HR+/HER2-早期乳腺癌、年龄≥70 岁女性的前哨淋巴结活检（SLNB），但对于行乳房切除术的 DCIS 且年龄≥70 岁女性，SLNB 是否可常规省略尚不清楚。本研究旨在评估该人群的腋窝手术和淋巴结阳性（pN+）率，以确定腋窝手术对治疗决策的影响。
从国家癌症数据库（2012-2020 年）中确定了行乳房切除术、年龄≥70 岁且患有 DCIS 的女性。评估了升级为浸润性癌（≥pT1）或 pN+的比例。对 ER+患者进行了亚组分析。对≥pT1 患者在按淋巴结状态分层后评估辅助治疗。
在 9030 例患者中，1896 例（21%）升级为≥pT1。86%的患者接受了腋窝手术，主要为前哨淋巴结活检（SLNB，65%）。应用选择明智标准的事后分析显示，93%的整个队列和 97%的 ER+DCIS 患者可以避免腋窝手术。未升级的患者中淋巴结阳性率为 0.3%，升级为≥pT1 的患者中为 12%，无论受体亚型如何，仅有<2%的患者为 pN2-3 疾病。阳性淋巴结患者的辅助治疗使用率更高，但仍有 71%和 66%的 pN+患者分别未推荐使用辅助化疗或放疗。
对于大多数行 ER+DCIS 乳房切除术、年龄≥70 岁的患者，可以省略腋窝手术，这与浸润性癌的建议一致，对于 ER-疾病的患者也可以考虑省略。未来的指南可能需要纳入术前影像学，如 SOUND 试验，以确定受益于腋窝手术的患者。
