Department of Surgery, Duke University Medical Center, Durham, NC, USA.
Duke Cancer Institute, Durham, NC, USA.
Ann Surg Oncol. 2024 Dec;31(13):8813-8820. doi: 10.1245/s10434-024-16143-6. Epub 2024 Sep 4.
Axillary management after neoadjuvant chemotherapy (NAC) is evolving but axillary lymph node dissection (ALND) remains the standard of care for patients with residual nodal disease. The results of the Alliance A011202 trial evaluating the oncologic safety of ALND omission in this cohort are pending but we hypothesize that ALND omission is already increasing.
The National Cancer Database was queried to identify patients diagnosed with cT1-3N1M0 breast cancer who underwent NAC and had residual nodal disease (ypN1mi-2) from 2012 to 2021. Temporal trends in omission of completion ALND were assessed annually. Multivariable logistic and Cox regression models were used to identify factors associated with ALND omission and overall survival (OS), respectively.
A total of 6101 patients were included; the majority presented with cT2 disease (57%), with 69% HER2+, 23% triple-negative, and 8% hormone receptor-positive/HER2-. Overall, 34% underwent sentinel lymph node biopsy (SLNB) alone. Rates of ALND were the lowest in the last 4 years of observation. After adjustment, treatment at community centers (vs. academic) and lower pathologic nodal burden were associated with omission of ALND. ALND omission was associated with a higher unadjusted OS (5-year OS: 86% SLNB alone vs. 84% ALND; log-rank p = 0.03), however this association was not maintained after adjustment.
Despite the impending release of the Alliance A011202 results, omission of ALND in patients with residual nodal disease after NAC is increasing. This practice appears more prominent in community centers and in patients with a lower burden of residual nodal disease. No association with OS was noted.
新辅助化疗（NAC）后腋窝管理正在发展，但腋窝淋巴结清扫（ALND）仍然是残留淋巴结疾病患者的标准治疗方法。评估该队列中 ALND 省略的肿瘤安全性的 Alliance A011202 试验结果尚未公布，但我们假设 ALND 省略已经在增加。
从 2012 年到 2021 年，国家癌症数据库被查询以确定接受 NAC 治疗且残留淋巴结疾病（ypN1mi-2）的 cT1-3N1M0 乳腺癌患者。每年评估省略完成性 ALND 的趋势。多变量逻辑回归和 Cox 回归模型分别用于确定与 ALND 省略和总生存（OS）相关的因素。
共纳入 6101 例患者；大多数患者表现为 cT2 疾病（57%），69% HER2+，23%三阴性，8%激素受体阳性/HER2-。总体而言，34%的患者仅接受前哨淋巴结活检（SLNB）。在观察的最后 4 年，ALND 的比例最低。调整后，在社区中心（与学术中心相比）和较低的病理淋巴结负担与 ALND 省略相关。ALND 省略与未经调整的更高 OS 相关（5 年 OS：SLNB 单独治疗组为 86%，ALND 组为 84%；log-rank p=0.03），但调整后这种相关性不再存在。
尽管即将公布 Alliance A011202 的结果，但在 NAC 后残留淋巴结疾病患者中省略 ALND 的情况正在增加。这种做法在社区中心和残留淋巴结疾病负担较低的患者中更为常见。未观察到与 OS 相关。
