Wang Ton, Neish Drew, Thomas Samantha M, Botty van den Bruele Astrid, Rosenberger Laura H, Chiba Akiko, Modell Parrish Kendra J, DiNome Maggie L, Dossett Lesly A, Scales Charles D, Zullig Leah L, Hwang E Shelley, Plichta Jennifer K
Department of Surgery, Duke University Medical Center, Durham, NC.
Duke Cancer Institute, Duke University, Durham, NC.
JCO Clin Cancer Inform. 2025 Mar;9:e2400186. doi: 10.1200/CCI-24-00186. Epub 2025 Mar 26.
Guidelines recommend omission of sentinel lymph node biopsy (SLNB) for axillary staging in select patients age 70 years and older with early-stage estrogen receptor-positive (ER+), human epidermal growth factor receptor 2 neu-negative (HER2-) invasive breast cancers (BCs). However, many women meeting criteria for SLNB omission continue to receive this procedure. This study aims to stratify patients into risk cohorts for nodal positivity that can be incorporated into deimplementation strategies to reduce low-value SLNB procedures.
A retrospective cohort analysis using the National Cancer Database was performed on patients age 70 years and older with ER+/HER2-, cT1-2, cN0, cM0 BC who underwent breast surgery from 2018 to 2021. Patients who received neoadjuvant therapies were excluded. Recursive partitioning analysis (RPA) was used to develop two models to estimate nodal positivity: (1) a clinical model for preoperative use to decide whether to perform SLNB and (2) a pathologic model for postoperative use to guide adjuvant decisions in cases of SLNB omission.
The study included 68,867 patients who received SLNB; 13.4% had a tumor-involved lymph node. RPA on the basis of clinical covariates demonstrated <8% risk of nodal positivity for patients with cT1mi-cT1b and grade 1-2 tumors. RPA on the basis of pathologic covariates found <10% risk of nodal positivity for patients with pT1 tumors without lymphovascular invasion (LVI). Patients with cT2 or pT2 without LVI and nonductal/nonlobular histology had <5% risk of nodal positivity.
This study demonstrates a low risk of nodal positivity for patients with cT1 or pT1 tumors. Our RPA-defined subgroups offer a novel approach to predict nodal positivity in patients age 70 years and older with early-stage, ER+/HER2- invasive BC that can be incorporated in deimplementation strategies to reduce low-value axillary surgery.
指南建议，对于年龄70岁及以上、早期雌激素受体阳性（ER+）、人表皮生长因子受体2 neu阴性（HER2-）浸润性乳腺癌（BC）的特定患者，可不进行前哨淋巴结活检（SLNB）以进行腋窝分期。然而，许多符合不进行SLNB标准的女性仍继续接受该手术。本研究旨在将患者分层为淋巴结阳性风险队列，可将其纳入去实施策略以减少低价值的SLNB手术。
使用国家癌症数据库对2018年至2021年期间接受乳房手术的年龄70岁及以上、ER+/HER2-、cT1-2、cN0、cM0 BC患者进行回顾性队列分析。排除接受新辅助治疗的患者。使用递归划分分析（RPA）开发两个模型来估计淋巴结阳性：（1）术前使用的临床模型，以决定是否进行SLNB；（2）术后使用的病理模型，在不进行SLNB的情况下指导辅助决策。
该研究纳入了68867例接受SLNB的患者；13.4%有肿瘤累及的淋巴结。基于临床协变量的RPA显示，cT1mi-cT1b和1-2级肿瘤患者的淋巴结阳性风险<8%。基于病理协变量的RPA发现，无淋巴管浸润（LVI）的pT1肿瘤患者的淋巴结阳性风险<10%。无LVI且非导管/非小叶组织学的cT2或pT2患者的淋巴结阳性风险<5%。
本研究表明，cT1或pT1肿瘤患者的淋巴结阳性风险较低。我们通过RPA定义的亚组为预测70岁及以上早期ER+/HER2-浸润性BC患者的淋巴结阳性提供了一种新方法，可将其纳入去实施策略以减少低价值的腋窝手术。
