University of Minnesota Medical School, Minneapolis, MN, USA.
Department of Surgery, University of California San Francisco, San Francisco, CA, USA.
Ann Surg Oncol. 2024 Oct;31(11):7249-7259. doi: 10.1245/s10434-024-15792-x. Epub 2024 Jul 12.
For patients with clinically node-positive (cN+) breast cancer undergoing neoadjuvant chemotherapy (NAC), retrieving previously clipped, biopsy-proven positive lymph nodes during sentinel lymph node biopsy [i.e., targeted axillary dissection (TAD)] may reduce false negative rates. However, the overall utilization and impact of clipping positive nodes remains uncertain.
We retrospectively analyzed cN+ ISPY-2 patients (2011-2022) undergoing axillary surgery after NAC. We evaluated trends in node clipping and associations with type of axillary surgery [sentinel lymph node (SLN) only, SLN and axillary lymph node dissection (ALND), or ALND only] and event-free survival (EFS) in patients that were cN+ on a NAC trial.
Among 801 cN+ patients, 161 (20.1%) had pre-NAC clip placement in the positive node. The proportion of patients that were cN+ undergoing clip placement increased from 2.4 to 36.2% between 2011 and 2021. Multivariable logistic regression showed nodal clipping was independently associated with higher odds of SLN-only surgery [odds ratio (OR) 4.3, 95% confidence interval (CI) 2.8-6.8, p < 0.001]. This was also true among patients with residual pathologically node-positive (pN+) disease. Completion ALND rate did not differ based on clip retrieval success. No significant differences in EFS were observed in those with or without clip placement, both with or without successful clip retrieval [hazard ratio (HR) 0.85, 95% CI 0.4-1.7, p = 0.7; HR 1.8, 95% CI 0.5-6.0, p = 0.3, respectively].
Clip placement in the positive lymph node before NAC is increasingly common. The significant association between clip placement and omission of axillary dissection, even among patients with pN+ disease, suggests a paradigm shift toward TAD as a definitive surgical management strategy in patients with pN+ disease after NAC.
对于接受新辅助化疗（NAC）的临床淋巴结阳性（cN+）乳腺癌患者，在进行前哨淋巴结活检（即靶向腋窝解剖术[TAD]）时，取出之前夹闭的活检证实阳性的淋巴结，可能会降低假阴性率。然而，夹闭阳性淋巴结的总体应用和影响仍不确定。
我们回顾性分析了 2011 年至 2022 年间接受 NAC 后行腋窝手术的 cN+ ISPY-2 患者。我们评估了夹闭淋巴结的趋势，并分析了其与腋窝手术类型（仅前哨淋巴结 [SLN]、SLN+腋窝淋巴结清扫术 [ALND]或仅 ALND）和无事件生存（EFS）的关系，这些患者在 NAC 试验中为 cN+。
在 801 例 cN+患者中，有 161 例（20.1%）在阳性淋巴结中接受了新辅助化疗前夹闭。在 2011 年至 2021 年间，接受新辅助化疗前夹闭的 cN+患者比例从 2.4%增加到 36.2%。多变量逻辑回归显示，淋巴结夹闭与 SLN 手术的几率显著增加相关（比值比 [OR] 4.3，95%置信区间 [CI] 2.8-6.8，p<0.001）。在残留病理淋巴结阳性（pN+）疾病的患者中，这一结果也是如此。根据夹闭的成功与否，完成 ALND 的比率没有差异。在有或没有夹闭的患者中，在有或没有成功夹闭的患者中，EFS 没有观察到显著差异[风险比（HR）0.85，95%CI 0.4-1.7，p=0.7；HR 1.8，95%CI 0.5-6.0，p=0.3，分别]。
在 NAC 前对阳性淋巴结进行夹闭越来越常见。夹闭与省略腋窝清扫术之间的显著关联，即使在 pN+疾病患者中也是如此，这表明 TAD 作为 NAC 后 pN+疾病患者的确定性手术管理策略正在发生转变。
