Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Ji Yan Road 440, Jinan, 250000, Shandong, People's Republic of China.
The 970th Hospital of the Chinese People's Liberation Army, Wehai, 264200, Shandong, People's Republic of China.
Sci Rep. 2024 Sep 3;14(1):20504. doi: 10.1038/s41598-024-70874-w.
For breast cancer patients with physical exam node negative but radiological finding node abnormal (cN0/rNa), the NCCN and ASCO guidelines recommend sentinel lymph node biopsy (SLNB) as the first-line axillary staging. However, patients who undergo surgery firstly may be upstaged to pathological II-III status, and these patients happen to be the adaptive population of neoadjuvant therapy (NAT). There is no consensus on the optimal management of cN0/rNa patients. The aim is to explore the optimal management strategy of these patients. We performed a retrospective real-world study of 1414 cN0/rNa patients from June 2014 to October 2022. There were 1003 patients underwent surgery first and 411 patients underwent surgery after NAT. We analyzed the real-world conditions of these patients, compared axilla tumor burden between these two groups. In addition, we compared benefit ratio of axillary surgery and regional nodal irradiation (RNI) de-escalation under the two strategies. Among 1003 patients underwent surgery first, the positive and negative rates of fine needle aspiration (FNA) were 18.5% and 81.5%, respectively. There were 66.1% had ≤ 2 lymph nodes+. There were 40.8% of FNA+ patients could be exempted from ALND underwent surgery first. In 411 patients underwent surgery after NAT, the FNA positive and negative rates were 60.8% and 49.2%, respectively. There were 54.4% of FNA+ patients achieved axilla pathologic complete response (apCR) and could omit ALND after NAT. The apCR was 67.3% in HER2+/TNBC subtypes. According to the NSABP-B51 trial, there were 0 and 54.4% of FNA+ patients could omit RNI among surgery first and after NAT, respectively. Among 1-2 sentinel lymph node (SLN)-positive patients underwent surgery first, with a median follow-up 49 months, there was no difference of survival benefit between SLNB-only and SLNB-ALND. Compared with 1-2 SLN+ patients without RNI, RNI could bring better invasive disease-free survival (97.38% vs. 89.36%, P = 0.046) and breast cancer special survival (100% vs. 94.68%, P = 0.020). It is safe to perform SLNB omitting ALND when detected 1-2 positive SLNs in cN0/rNa patients. Patients with HER2+/TNBC subtypes underwent surgery after NAT had more chance to benefit from dual de-escalation, including axillary surgery and RNI de-escalation.
对于体格检查淋巴结阴性但影像学发现淋巴结异常的乳腺癌患者（cN0/rNa），NCCN 和 ASCO 指南推荐前哨淋巴结活检（SLNB）作为首选的腋窝分期方法。然而，首先接受手术的患者可能会被升级为病理 II-III 期，而这些患者恰好是新辅助治疗（NAT）的适应人群。对于 cN0/rNa 患者，目前尚无最佳的管理共识。本研究旨在探讨此类患者的最佳管理策略。我们对 2014 年 6 月至 2022 年 10 月期间的 1414 例 cN0/rNa 患者进行了回顾性真实世界研究。其中 1003 例患者首先接受手术，411 例患者在 NAT 后接受手术。我们分析了这些患者的真实情况，比较了两组患者的腋窝肿瘤负荷。此外，我们比较了两种策略下腋窝手术和区域淋巴结照射（RNI）降级的获益比。在首先接受手术的 1003 例患者中，细针穿刺（FNA）的阳性率和阴性率分别为 18.5%和 81.5%。有 66.1%的患者有≤2 个淋巴结阳性。有 40.8%的 FNA+患者可以免除首先接受 ALND 手术。在 411 例首先接受 NAT 的患者中，FNA 的阳性率和阴性率分别为 60.8%和 49.2%。有 54.4%的 FNA+患者达到了腋窝病理完全缓解（apCR），并在 NAT 后可以避免 ALND。HER2+/TNBC 亚型的 apCR 为 67.3%。根据 NSABP-B51 试验，首先接受手术的 FNA+患者中，有 0 例和 54.4%例可避免 RNI，分别接受 NAT 后。在首先接受手术的 1-2 个前哨淋巴结（SLN）阳性患者中，中位随访 49 个月，SLNB 仅与 SLNB-ALND 之间的生存获益无差异。与未接受 RNI 的 1-2 个 SLN+患者相比，RNI 可带来更好的无侵袭性疾病生存（97.38%比 89.36%，P=0.046）和乳腺癌特异性生存（100%比 94.68%，P=0.020）。在 cN0/rNa 患者中，当检测到 1-2 个阳性 SLN 时，进行 SLNB 省略 ALND 是安全的。接受 NAT 治疗的 HER2+/TNBC 亚型患者有更多机会从双重降级中获益，包括腋窝手术和 RNI 降级。
