Kuerer H M, Newman L A, Fornage B D, Dhingra K, Hunt K K, Buzdar A U, Ames F C, Ross M I, Feig B W, Hortobagyi G N, Singletary S E
Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston 77030, USA.
Ann Surg Oncol. 1998 Dec;5(8):673-80. doi: 10.1007/BF02303476.
Induction chemotherapy has become the standard of care for patients with locally advanced breast cancer (LABC) and currently is being evaluated in prospective clinical trials in patients with earlier-stage disease. To better gauge the role of axillary lymph node dissection in patients with LABC this study was performed to assess initial axillary status on physical and ultrasound examination, axillary tumor downstaging following induction chemotherapy, and the accuracy of physical examination compared with axillary sonography in predicting which patients will have axillary lymph node metastases found on pathologic examination.
Between 1992 and 1996, 147 consecutive patients with LABC were registered in a prospective trial of induction chemotherapy using 5-fluorouracil, doxorubicin, and cyclophosphamide. Physical and ultrasound examinations of the axilla were performed at diagnosis and after induction chemotherapy. Segmental resection with axillary lymph node dissection or modified radical mastectomy was performed, followed by postoperative chemotherapy and irradiation of the breast or chest wall and regional lymphatics.
Following induction chemotherapy, 43 (32%) of the 133 patients with clinically positive lymph nodes on initial examination had axillary tumor downstaging as assessed by physical and ultrasound examination. The sensitivity of axillary sonography in identifying axillary metastases was significantly higher than that of physical examination (62% vs. 45%, P=.012). The specificity of physical examination (84%) was higher than that of sonography (70%), but the difference did not reach statistical significance. Among the 55 patients in whom the findings of both physical and ultrasound examination of the axilla were negative following induction chemotherapy, 29 patients (53%) were found to have axillary lymph node metastases on pathologic examination of the axillary contents. However, 28 (97%) of these patients had either 1 to 3 positive lymph nodes or only micrometastases 2 to 5 mm in diameter.
Preoperative clinical assessment of the axilla by physical examination combined with ultrasound examination is not completely accurate in predicting metastases in patients with LABC following tumor downstaging. However, patients with negative findings on both physical and ultrasound examinations of the axilla may be potential candidates for omission of axillary dissection if the axilla will be irradiated because minimal axillary disease remains. Patients who have positive findings on preoperative physical or ultrasound examinations should receive axillary dissection to ensure local control. A prospective randomized trial of axillary dissection versus axillary radiotherapy in patients with a clinically negative axilla following induction chemotherapy is currently underway.
诱导化疗已成为局部晚期乳腺癌（LABC）患者的标准治疗方法，目前正在早期疾病患者的前瞻性临床试验中进行评估。为了更好地评估腋窝淋巴结清扫术在LABC患者中的作用，本研究旨在评估体格检查和超声检查时的初始腋窝状态、诱导化疗后的腋窝肿瘤降期情况，以及体格检查与腋窝超声检查在预测哪些患者病理检查会发现腋窝淋巴结转移方面的准确性。
1992年至1996年期间，147例连续的LABC患者登记参加了一项使用5-氟尿嘧啶、阿霉素和环磷酰胺进行诱导化疗的前瞻性试验。在诊断时和诱导化疗后对腋窝进行体格检查和超声检查。进行了腋窝淋巴结清扫的节段性切除或改良根治性乳房切除术，随后进行术后化疗以及乳房或胸壁和区域淋巴结的放疗。
诱导化疗后，133例初始检查临床淋巴结阳性的患者中，有43例（32%）经体格检查和超声检查评估腋窝肿瘤降期。腋窝超声检查识别腋窝转移的敏感性显著高于体格检查（62%对45%，P = 0.012）。体格检查的特异性（84%）高于超声检查（70%），但差异未达到统计学意义。在诱导化疗后腋窝体格检查和超声检查结果均为阴性的55例患者中，29例（53%）在腋窝内容物的病理检查中发现有腋窝淋巴结转移。然而，这些患者中有28例（97%）有1至3个阳性淋巴结或仅为直径2至5毫米的微转移灶。
体格检查结合超声检查对LABC患者肿瘤降期后的腋窝转移进行术前临床评估并不完全准确。然而，如果腋窝将接受放疗，因为残留的腋窝疾病极少，腋窝体格检查和超声检查结果均为阴性的患者可能是省略腋窝清扫的潜在候选人。术前体格检查或超声检查结果为阳性的患者应接受腋窝清扫以确保局部控制。目前正在进行一项关于诱导化疗后临床腋窝阴性的患者腋窝清扫与腋窝放疗的前瞻性随机试验。
