临床淋巴结阳性新辅助治疗后腋窝降阶处理的研究进展

doi:10.19401/j.cnki.1007-3639.2023.02.011

中国癌症杂志 ›› 2023, Vol. 33 ›› Issue (2): 174-180.doi: 10.19401/j.cnki.1007-3639.2023.02.011

临床淋巴结阳性新辅助治疗后腋窝降阶处理的研究进展

樊庆达¹^,²(), 丛斌斌¹^,², 陈玉光¹^,², 段宝伟¹^,²^,³, 王永胜¹^,²()

1.山东第一医科大学（山东省医学科学院）研究生部，山东济南 250118
2.山东省肿瘤防治研究院（山东省肿瘤医院）乳腺病中心，山东第一医科大学（山东省医学科学院），山东济南 250117
3.泰安市肿瘤防治院乳腺外科，山东泰安 271000

收稿日期:2022-10-26 修回日期:2022-11-28 出版日期:2023-02-28 发布日期:2023-03-22
通信作者: 王永胜（ORCID: 0000-0001-6252-684X），博士，主任医师，山东省肿瘤医院乳腺病中心主任。
作者简介:樊庆达（ORCID: 0000-0001-5815-131X），硕士研究生。
基金资助:
国家自然科学基金(81672638);山东省自然科学基金(ZR2021QH164)

Research progress of axillary de-escalation management after neoadjuvant chemotherapy for clinical lymph node positive patients

FAN Qingda¹^,²(), CONG Binbin¹^,², CHEN Yuguang¹^,², DUAN Baowei¹^,²^,³, WANG Yongsheng¹^,²()

1. Graduate Department of Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan 250118, Shandong Province, China
2. Department of Breast Cancer Center, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan 250117, Shandong Province, China
3. Department of Breast Surgery, Taian Tumor Hospital, Taian 271000, Shandong Province, China

Received:2022-10-26 Revised:2022-11-28 Published:2023-02-28 Online:2023-03-22
Contact: WANG Yongsheng

摘要/Abstract

摘要：

在优效系统治疗和精准放疗的时代背景下，乳腺癌新辅助治疗（neoadjuvant treatment，NAT）有助于乳房肿瘤降期实现保乳和腋窝降期，使患者豁免腋窝淋巴结清扫（axillary lymph node dissection，ALND）。目前，在临床腋窝淋巴结阳性的患者中，人表皮生长因子受体2（human epidermal growth factor receptor 2，HER2）阳性和三阴性乳腺癌（triple-negative breast cancer，TNBC）亚型接受NAT后可达到较高的腋窝病理学完全缓解率（axillary nodal pathologic complete response，apCR），有望实现腋窝局部降阶梯处理，相关指南与专家共识推荐初始临床淋巴结阴性（clinical lymph node negative，cN₀）的患者NAT后前哨淋巴结（sentinel lymph node，SLN）阴性可行前哨淋巴结活检（sentinel lymph node biopsy，SLNB）替代ALND，NAT后SLN存在较低肿瘤残留负荷的患者可考虑放疗替代ALND。初始临床淋巴结阳性（clinical lymph node positive，cN⁺）患者NAT后转为ycN₀接受常规SLNB的可行性依然受到质疑，主要障碍是NAT后SLNB的假阴性率较高，不能准确预测腋窝肿瘤细胞残留且不能明确术后腋窝复发转移风险。在联合示踪、SLN检出数目≥3枚、临床腋窝转移肿瘤负荷较低的条件下，SLNB的假阴性率可能会满足临床需求。然而，由于肿瘤细胞阻塞淋巴管，影响蓝染料或放射性核素的引流等原因，NAT后SLNB的质量并不能得到有效的改善。因此，需要实现NAT后SLNB技术的优化。靶向腋窝淋巴结切除术（targeted axillary lymph node dissection，TAD）是对NAT前穿刺证实转移的腋窝淋巴结放置标记夹并在NAT后SLNB时靶向检出的精准外科手术操作技术，可以进一步降低NAT后SLNB的假阴性率、实现NAT后腋窝淋巴结肿瘤残留负荷的准确评估。对于NAT后转阴的乳腺癌患者，TAD有望成为NAT后腋窝降期患者安全、可靠的腋窝分期技术。本文就初始cN⁺患者NAT后腋窝降阶梯处理及TAD研究进展进行综述。

关键词: 乳腺癌, 前哨淋巴结活检, 靶向腋窝淋巴结切除术, 新辅助治疗

Abstract:

In the era of effective systemic therapy and precise radiotherapy, neoadjuvant treatment (NAT) for breast cancer can de-escalate breast cancer treatment to conserve breast and spare axillary lymph node dissection (ALND). At present, high axillary nodal pathologic complete response (apCR) is achieved in patients with human epidermal growth factor receptor 2 (HER2)-positive and triple-negative breast cancer (TNBC), and it is hopeful to realize the axillary de-escalation management. It is recommended that sentinel lymph node (SLN) biopsy (SLNB) is a feasible alternative to ALND in primary clinical lymph node negative (cN₀) patients, and the presence of lower residual tumor burden in SLN after NAT may be considered as a replacement for ALND with radiotherapy. The feasibility of the patients with initial clinical lymph node positive (cN⁺) turning to conventional SLNB after NAT is still being questioned. The main obstacle is the high false negative rate of SLNB after NAT, residual tumor cells in the axilla cannot be accurately predicted, and the risk of postoperative axillary recurrence and metastasis cannot be determined. The false negative rate of SLNB may meet the clinical requirement under the condition of combined tracing, more than 3 SLNs detected, and lower clinical axillary metastatic tumor burden. However, the quality of SLNB after NAT cannot be effectively improved due to tumor cells blocking lymphatic vessels and affecting the drainage of blue dye or radionuclide. Therefore, optimization of SLNB technology needs to be implemented after NAT. Targeted axillary lymph node dissection (TAD) is a precise surgical procedure for the detection of metastatic axillary lymph nodes, and clips were placed on the metastatic lymph nodes before NAT and targeted to detect the lymph nodes after NAT. It can further reduce the false negative rate of SLNB after NAT and improve the accurate assessment of residual tumor burden in axillary lymph nodes after NAT. TAD is expected to be a safe and reliable axillary staging technique for breast cancer patients after NAT. This article reviewed the de-escalation treatment of NAT in initial cN+ patients and the research progress of TAD.

Key words: Breast cancer, Sentinel lymph node biopsy, Targeted axillary lymph node dissection, Neoadjuvant treatment

中图分类号:

R737.9

樊庆达, 丛斌斌, 陈玉光, 段宝伟, 王永胜. 临床淋巴结阳性新辅助治疗后腋窝降阶处理的研究进展[J]. 中国癌症杂志, 2023, 33(2): 174-180.

FAN Qingda, CONG Binbin, CHEN Yuguang, DUAN Baowei, WANG Yongsheng. Research progress of axillary de-escalation management after neoadjuvant chemotherapy for clinical lymph node positive patients[J]. China Oncology, 2023, 33(2): 174-180.

图/表 1

参考文献 33

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Study	Year	Number of false negative	Total patients	Method of marking target lymph node (MLN)	Localization method	False negative rate/%
Caudle A S, et al^[3]	2016	1	74	Metallic clip	¹²⁵I seed	1.4
Kuemmel S, et al^[15]	2020	2	46	Metallic clip	Wire guided	4.3
Mariscal Martínez A, et al^[18]	2021	1	17	Metallic clip	Magseed	5.9
Flores-Funes D, et al^[32]	2019	0	23	Metallic clip	Wire guided	0.0
Gatek J, et al^[33]	2020	0	8	Carbon tattooing	-	0.0

临床淋巴结阳性新辅助治疗后腋窝降阶处理的研究进展

Research progress of axillary de-escalation management after neoadjuvant chemotherapy for clinical lymph node positive patients

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