Fleshner Katherine, Xu Yuan, Isherwood Susan, Yang Flora, Pyo Jade, Blair Akaya, Hall Juliette, Hanniman Emily, Bouchard-Fortier Antoine, Quan May Lynn
Department of Surgery, University of Calgary, Calgary, AB, Canada.
Department of Oncology, Arthur Child Comprehensive Cancer Centre, Calgary, AB, Canada.
Ann Surg Oncol. 2025 Jun;32(6):3975-3983. doi: 10.1245/s10434-025-17041-1. Epub 2025 Feb 19.
There is limited level I evidence guiding axillary management in patients with node-positive breast cancer downstaged post-neoadjuvant chemotherapy (NAC) to clinically node-negative. We aimed to describe practice patterns among cN+ patients after NAC and examine predictors of subsequent completion axillary lymph node dissection (cALND) and recurrence among patients who initially underwent sentinel lymph node biopsy (SLNB).
This was a retrospective, population-based cohort of patients with cN+ breast cancer who underwent NAC then surgery in Alberta from January 2016 to September 2021. Practice patterns were described. Chart review was performed for patients receiving definitive SLNB at the index surgery; the outcomes were rates of subsequent cALND and recurrence.
The total cohort comprised 850 patients. Median age was 52 years, 584 patients (68.7%) had cT1/T2 disease before NAC, and 395 patients (46.5%) were HR+/HER2-. A total of 472 patients (55.5%) underwent SLNB but 108 were converted intraoperatively to ALND. On final pathology, 189/364 (51.9%) had a pathologic complete response, and most (95.1%) had adjuvant RT. Only 39 ypN+ patients (22.2%) had a cALND. After a median of 46.7 months, 52/364 (14.3%) patients recurred; 7/10 patients with regional recurrence did not undergo cALND, but 2 subsequently underwent salvage ALND. On multivariate analysis, very high/low body mass index (BMI), triple-negative disease, cT3/4 disease pre-NAC, and positive SLNB were predictors of recurrence.
Uptake of cALND for ypN+ patients in a real-world setting with frequent administration of RT was lower than expected. Regional recurrences were rare, suggesting that a nuanced approach to cALND may be feasible.
对于新辅助化疗（NAC）后降期至临床淋巴结阴性的淋巴结阳性乳腺癌患者，指导腋窝处理的I级证据有限。我们旨在描述NAC后cN+患者的治疗模式，并检查最初接受前哨淋巴结活检（SLNB）的患者后续完成腋窝淋巴结清扫（cALND）和复发的预测因素。
这是一项基于人群的回顾性队列研究，研究对象为2016年1月至2021年9月在艾伯塔省接受NAC然后手术的cN+乳腺癌患者。描述了治疗模式。对在初次手术时接受确定性SLNB的患者进行病历审查；结局指标为后续cALND和复发率。
总队列包括850例患者。中位年龄为52岁，584例患者（68.7%）在NAC前患有cT1/T2疾病，395例患者（46.5%）为HR+/HER2-。共有472例患者（55.5%）接受了SLNB，但108例在术中转为ALND。最终病理检查显示，189/364例（51.9%）达到病理完全缓解，大多数（95.1%）接受了辅助放疗。只有39例ypN+患者（22.2%）进行了cALND。中位随访46.7个月后，52/364例（14.3%）患者复发；10例区域复发患者中有7例未进行cALND，但其中2例随后接受了挽救性ALND。多因素分析显示，极高/低体重指数（BMI）、三阴性疾病、NAC前cT3/4疾病以及SLNB阳性是复发的预测因素。
在实际临床中，对于ypN+患者，在频繁进行放疗的情况下，cALND的实施率低于预期。区域复发罕见，这表明对cALND采取细致入微的方法可能是可行的。
