乳腺癌新辅助治疗后腋窝淋巴结转移情况分析

doi:10.19401/j.cnki.1007-3639.2023.04.006

摘要/Abstract

摘要：

背景与目的：多项指南及共识已确认临床淋巴结阳性（clinical nodal positive，cN⁺）且新辅助治疗（neoadjuvant therapy，NAT）后降期转阴患者接受前哨淋巴结活检（sentinel lymph node biopsy，SLNB）的可行性，但分析cN⁺患者NAT后腋窝淋巴结（axillary lymph node，ALN）各解剖分区转移情况的研究较少。本研究的目的是探索NAT后各腋窝解剖分区ALN的转移情况，为NAT后腋窝降阶梯手术管理提供更充实的理论依据。方法：回顾性分析2018年4月—2020年4月山东省肿瘤防治研究院（山东省肿瘤医院）乳腺病中心收治499例接受NAT的cN⁺患者临床病理学参数，其中157例患者NAT后降期转阴接受SLNB联合腋窝淋巴结清扫（axillary lymph node dissection，ALND），342例患者直接行ALND。同时入组2020年5月—2020年12月山东省肿瘤防治研究院（山东省肿瘤医院）乳腺病中心收治46例临床淋巴结（clinical lymph node，cN）状态为cN₁且NAT后降期转阴同时接受靶向腋窝清扫（target axillary dissection，TAD）患者，这部分患者NAT前在超声引导下于阳性ALN放置标记夹，并于术中取出将其作为前哨淋巴结（sentinel lymph node，SLN）。分析各解剖分区ALN转移情况。结果：入组499例患者NAT后ALN“跳跃式转移”率仅为0.8%（4/499），SLNB联合ALND组和直接ALND组分别为0.5%和1.0%。NAT后SLN阳性患者中，非SLN（non-SLN，NSLN）阳性率为41.4%。NAT后SLN阴性患者中，NSLN转移率为10.1%，其中cN₁、cN₂和cN₃亚组中NSLN阳性率分别为8.1%、8.7%和21.3%。初诊cN₁亚组NAT后SLN阴性患者，SLN 1枚、2枚和3枚阴性时NSLN阳性率分别为11.8%、4.6%和0.0%。初诊cN₁且NAT后接受TAD患者，SLN阴性患者NSLN转移率为4.3%，SLN 1枚、2枚和3枚阴性时NSLN阳性率分别为5%、5%和0%，且与检出的阴性SLN数目无关。结论：初诊cN⁺患者若NAT后SLN阳性，ALND仍是标准处理。初诊cN₁患者若采用TAD标记SLN，接受SLNB豁免ALND时可能不再需要考虑阴性SLN数目。

关键词: 乳腺癌, 新辅助治疗, 前哨淋巴结活检, 靶向腋窝清扫技术, 腋窝淋巴结

Abstract:

Background and purpose: Multiple guidelines and consensus have confirmed the feasibility of sentinel lymph node biopsy (SLNB) after neoadjuvant therapy (NAT) in clinical nodal positive (cN⁺) patients converting to negative after NAT. There are few studies on the metastasis of axillary lymph node (ALN) at each anatomic level after NAT. This study aimed to explore the metastasis of ALN in each anatomic level, in order to provide more basis for the axillary de-escalation management after NAT. Methods: From April 2018 to 2020, 499 patients in Shandong Cancer Hospital were enrolled in this study. Patients (n=157) with initial cN⁺ and ycN₀ disease after NAT underwent SLNB plus axillary lymph node dissection (ALND). Patients (n=342) with initial cN⁺ and ycN⁺ disease after NAT had undergone ALND directly. At the same time, from May 2020 to December 2020, 46 patients with initial cN₁ and ycN₀ disease after NAT underwent targeted axillary dissection (TAD). These patients underwent clip insertion into the most suspicious ALN. Axillary surgery was performed with SLNB plus ALND. The ALN status at each anatomic level was analyzed. Results: Among the 499 patients, the incidence of ALN “skip metastasis” was 0.8% (4/499), similar to those patients without NAT, and it was 0.5% and 1.0% in SLNB group and directly ALND, respectively. Out of the sentinel lymph node (SLN)-positive patients after NAT, 41.4% of them had positive non-SLN (NSLN). Out of the SLN-negative patients after NAT, 10.1% of them had positive NSLNs, and the rates of positive NSLNs were 8.1% (5/62), 8.7% (2/23) and 21.3% (3/11) in cN₁, cN₂, and cN₃ subgroups, respectively. In the cN₁ subgroup, the NSLNs metastasis rate were 11.8% (4/34), 4.6% (1/22), and 0.0% (0/6) when patients had 1, 2, and 3 negative SLN, respectively. Among the 46 patients receiving TAD, if clips were inserted into the most suspicious ALNs and removed during surgery, the incidence of positive NSLN was 4.3% (2/46). The rates of positive NSLN were 5% (1/20), 5% (1/20), and 0% (0/6) when 1, 2, and 3 negative SLNs were detected, respectively, and it was not related to the number of detected negative SLN. Conclusion: ALND is still the standard axillary treatment in SLN-positive patients after NAT. For patient with initial cN₁ and ycN₀ disease after NAT, if clips were used to identify biopsied lymph nodes at diagnosis, the number of negative SLN might be no longer the requirement for SLNB to omit ALND after NAT.

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

中图分类号:

R737.9

毕钊, 陈鹏, 邱鹏飞, 陈玉光, 王永胜. 乳腺癌新辅助治疗后腋窝淋巴结转移情况分析[J]. 中国癌症杂志, 2023, 33(4): 361-367.

BI Zhao, CHEN Peng, QIU Pengfei, CHEN Yuguang, WANG Yongsheng. The analysis of axillary lymph nodes metastasis after neoadjuvant therapy in breast cancer[J]. China Oncology, 2023, 33(4): 361-367.

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Characteristics	Patients n (%)
Molecular subtypes
HER2⁺	219 (43.9)
TNBC	204 (40.9)
HR⁺/HER2^-	76 (15.2)
Clinical nodal stage
cN₁	305 (61.1)
cN₂	130 (26.1)
cN₃	64 (12.8)
Clinical tumor stage
cT₁	44 (8.9)
cT₂	254 (50.9)
cT₃	83 (16.6)
cT₄	118 (23.6)
Axillary surgery
SLNB+ALND	157 (31.5)
ALND	342 (68.5)

SLN⁺	Status of ALN at different levels			Patients n (%)
SLN⁺	L1	L2	L3	Patients n (%)
cN₁ group	-	-	-	23 (67.6)
	-	+	+	0 (0.0)
	-	-	+	0 (0.0)
	-	+	-	0 (0.0)
	+	-	-	6 (17.6)
	+	-	+	1 (3.0)
	+	+	-	3 (8.8)
	+	+	+	1 (3.0)
cN₂ group	-	-	-	9 (50.0)
	-	+	+	0 (0.0)
	-	-	+	0 (0.0)
	-	+	-	0 (0.0)
	+	-	-	5 (27.7)
	+	-	+	1 (5.6)
	+	+	-	1 (5.6)
	+	+	+	2 (11.1)
cN₃ group	-	-	-	2 (33.2)
	-	+	+	0 (0.0)
	-	-	+	0 (0.0)
	-	+	-	1 (16.7)
	+	-	-	1 (16.7)
	+	-	+	1 (16.7)
	+	+	-	0 (0.0)
	+	+	+	1 (16.7)

SLN^-	Status of ALN at different levels			Patients n (%)
SLN^-	L1	L2	L3	Patients n (%)
cN₁ group	-	-	-	57 (91.9)
	-	+	+	0 (0.0)
	-	-	+	0 (0.0)
	-	+	-	0 (0.0)
	+	-	-	4 (6.5)
	+	-	+	0 (0.0)
	+	+	-	0 (0.0)
	+	+	+	1 (1.6)
cN₂ group	-	-	-	21 (91.3)
	-	+	+	0 (0.0)
	-	-	+	0 (0.0)
	-	+	-	0 (0.0)
	+	-	-	2 (8.7)
	+	-	+	0 (0.0)
	+	+	-	0 (0.0)
	+	+	+	0 (0.0)
cN₃ group	-	-	-	111 (78.7)
	-	+	+	1 (7.1)
	-	-	+	0 (0.0)
	-	+	-	0 (0.0)
	+	-	-	1 (7.1)
	+	-	+	0 (0.0)
	+	+	-	0 (0.0)
	+	+	+	1 (7.1)

Negative SLN	Status of ALN at different levels			Patients n (%)
Negative SLN	L1	L2	L3	Patients n (%)
1 SLN^-	-	-	-	30 (88.2)
	-	+	+	0 (0.0)
	-	-	+	0 (0.0)
	-	+	-	0 (0.0)
	+	-	-	3 (8.8)
	+	-	+	0 (0.0)
	+	+	-	0 (0.0)
	+	+	+	1 (3.0)
2 SLN^-	-	-	-	21 (95.5)
	-	+	+	0 (0.0)
	-	-	+	0 (0.0)
	-	+	-	0 (0.0)
	+	-	-	1 (4.5)
	+	-	+	0 (0.0)
	+	+	-	0 (0.0)
	+	+	+	0 (0.0)
3 SLN^-	-	-	-	6 (100.0)
	-	+	+	0 (0.0)
	-	-	+	0 (0.0)
	-	+	-	0 (0.0)
	+	-	-	0 (0.0)
	+	-	+	0 (0.0)
	+	+	-	0 (0.0)
	+	+	+	0 (0.0)