乳腺癌新辅助治疗后的腋窝管理及前哨淋巴结诊治的优化

钟佳倩; 李家平; 谢晓燕; 郑艳玲

doi:10.19401/j.cnki.1007-3639.2025.09.009

您当前的位置：

首页 >

文章列表页 >

乳腺癌新辅助治疗后的腋窝管理及前哨淋巴结诊治的优化

综述 | 更新时间：2025-12-31

- 乳腺癌新辅助治疗后的腋窝管理及前哨淋巴结诊治的优化
- Axillary management after neoadjuvant therapy for breast cancer and optimization of sentinel lymph node diagnosis and treatment
- 中国癌症杂志 2025年35卷第9期页码：884-892
- 作者机构：
  
  中山大学附属第一医院超声医学科，广东广州 510080
- 作者简介：
  
  [ "钟佳倩（ORCID: 0000-0002-1509-659X），硕士研究生在读。" ]
  郑艳玲（ORCID: 0000-0001-6032-0442），医学博士学位，主任医师，中山大学附属第一医院超声医学科副主任、支部书记。
- 基金信息：
- DOI：10.19401/j.cnki.1007-3639.2025.09.009
  中图分类号： R737.9
- 收稿：2025-02-14，
  
  修回：2025-06-12，
  
  纸质出版：2025-09-30
- 稿件说明：
移动端阅览
钟佳倩, 李家平, 谢晓燕, 等. 乳腺癌新辅助治疗后的腋窝管理及前哨淋巴结诊治的优化[J]. 中国癌症杂志, 2025,35(9):884-892.

Jiaqian ZHONG, Jiaping LI, Xiaoyan XIE, et al. Axillary management after neoadjuvant therapy for breast cancer and optimization of sentinel lymph node diagnosis and treatment[J]. China Oncology, 2025, 35(9): 884-892.
钟佳倩, 李家平, 谢晓燕, 等. 乳腺癌新辅助治疗后的腋窝管理及前哨淋巴结诊治的优化[J]. 中国癌症杂志, 2025,35(9):884-892. DOI： 10.19401/j.cnki.1007-3639.2025.09.009.

Jiaqian ZHONG, Jiaping LI, Xiaoyan XIE, et al. Axillary management after neoadjuvant therapy for breast cancer and optimization of sentinel lymph node diagnosis and treatment[J]. China Oncology, 2025, 35(9): 884-892. DOI： 10.19401/j.cnki.1007-3639.2025.09.009.

摘要

乳腺癌患者新辅助治疗（neoadjuvant therapy，NAT）后的腋窝管理正在优化，目前针对腋窝淋巴结（axillary lymph node，ALN）状态的评估，前哨淋巴结活检（sentinel lymph node biopsy，SLNB）已经成为重要手段，尤其是在初始临床ALN阴性（clinically negative ALN，cN0）的早期乳腺癌患者中，可以替代传统的ALN清扫（ALN dissection，ALND），减少不必要的手术风险和并发症，但是SLNB在初始临床ALN阳性（clinically positive ALN，cN

）的乳腺癌患者NAT后的应用上存在着一些假阴性率（false negative rate，FNR）及差异。通过切除≥3个SLN、使用双重示踪剂（如放射性核素联合蓝染料）或结合免疫组织化学（immuno

histochemistry，IHC）进行病理学评估，可将其FNR显著降低至可接受范围（4.9%~9.1%），并且发展出多种优化方案如放射性碘粒子标记ALN（marking ALN with radioactive iodine，MARI）、靶向腋窝清扫（targeted axillary dissection，TAD）、放射性碘粒子标记联合SLNB（radioactive iodine seed placement in the axilla with SLNB，RISAS），均表现出低FNR。不仅如此，非侵入性影像技术如正电子发射计算机体层成像（positron emission tomography and computed tomography，PET/CT）、磁共振成像（magnetic resonance imaging，MRI）、常规超声及超声造影（contrast-enhanced ultrasound，CEUS）都可以用于评估NAT后的腋窝反应，其诊断效能各异。本文对近年来cN

的乳腺癌患者NAT后的腋窝管理及SLNB诊治优化的相关研究进行总结。

Abstract

The axillary management of breast cancer patients after neoadjuvant therapy (NAT) is undergoing optimization. Sentinel lymph node biopsy (SLNB) has become an important means for evaluating the status of axillary lymph node (ALN)

especially in early-stage breast cancer patients with initially clinically negative ALN (cN0)

where it can replace traditional ALN dissection (ALND) to reduce unnecessary surgical risks and complications. However

SLNB has some limitations in terms of false negative rate (FNR) and variability when applied to breast cancer patients with initially clinically positive ALN (cN

) after NAT. By removing ≥3 SLN

using dual tracers (such as radioactive isotopes combined with blue dye)

and conducting pathological assessment in combination with immunohistochemistry (IHC)

the FNR can be significantly reduced to an acceptable range (4.9%-9.1%). Moreover

various optimization schemes have been developed

such as marking ALN with radioactive iodine (MARI)

targeted axillary dissection (TAD)

and radioactive iodine seed placement in the axilla with SLNB (RISAS)

all of which demonstrate low FNR. Not only that

non-invasive imaging techniques such as positron emission tomography and computed tomography (PET/CT)

magnetic resonance imaging (MRI)

conventional ultrasound and contrast-enhanced ultrasound (CEUS) can all be used to evaluate the axillary response after NAT

with varying diagnostic efficacies. This art

icle summarized recent studies on the optimization of axillary management and SLNB diagnosis and treatment for breast cancer patients with cN

after NAT.

关键词

Keywords

references

SIEGEL R L , GIAQUINTO A N , JEMAL A . Cancer statistics, 2024 [J ] . CA A Cancer J Clinicians , 2024 , 74 ( 1 ): 12 - 49 .

《中国乳腺癌新辅助治疗专家共识(2022年版)》专家组 . 中国乳腺癌新辅助治疗专家共识(2022年版) [J ] . 中国癌症杂志 , 2022 , 32 ( 1 ): 80 - 88 . DOI: 10.19401/j.cnki.1007-3639.2022.01.011 http://doi.org/10.19401/j.cnki.1007-3639.2022.01.011

Expert group of expert consensus on neoadjuvant treatment of breast cancer in China (2022 edition) . Expert consensus on neoadjuvant treatment of breast cancer in China (2022 edition) [J ] . China Oncol , 2022 , 32 ( 1 ): 80 - 88 .

FERRARAZZO G , NIERI A , FIRPO E , et al. The role of sentinel lymph node biopsy in breast cancer patients who become clinically node-negative following neo-adjuvant chemotherapy: a literature review [J ] . Curr Oncol , 2023 , 30 ( 10 ): 8703 - 8719 . DOI: 10.3390/curroncol30100630 http://doi.org/10.3390/curroncol30100630

SHIRZADI A , MAHMOODZADEH H , QORBANI M . Assessment of sentinel lymph node biopsy after neoadjuvant chemotherapy for breast cancer in two subgroups: initially node negative and node positive converted to node negative-a systemic review and meta-analysis [J ] . J Res Med Sci , 2019 , 24 : 18 .

VÁZQUEZ J C , PIÑERO A , DE CASTRO F J , et al. The value of sentinel lymph-node biopsy in women with node-positive breast cancer at diagnosis and node-negative tumour after neoadjuvant therapy: a systematic review [J ] . Clin Transl Oncol , 2023 , 25 ( 2 ): 417 - 428 .

BOUGHEY J C , SUMAN V J , MITTENDORF E A , et al. Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: the ACOSOG Z1071 (alliance) clinical trial [J ] . JAMA , 2013 , 310 ( 14 ): 1455 - 1461 . DOI: 10.1001/jama.2013.278932 http://doi.org/10.1001/jama.2013.278932

BOILEAU J F , POIRIER B , BASIK M , et al. Sentinel node biopsy after neoadjuvant chemotherapy in biopsy-proven node-positive breast cancer: the SN FNAC study [J ] . J Clin Oncol , 2015 , 33 ( 3 ): 258 - 264 .

KUEHN T , BAUERFEIND I , FEHM T , et al. Sentinel-lymph-node biopsy in patients with breast cancer before and after neoadjuvant chemotherapy (SENTINA): a prospective, multicentre cohort study [J ] . Lancet Oncol , 2013 , 14 ( 7 ): 609 - 618 . DOI: 10.1016/S1470-2045(13)70166-9 http://doi.org/10.1016/S1470-2045(13)70166-9

CAO S Y , LIU X , CUI J W , et al. Feasibility and reliability of sentinel lymph node biopsy after neoadjuvant chemotherapy in breast cancer patients with positive axillary nodes at initial diagnosis: an up-to-date meta-analysis of 3, 578 patients [J ] . Breast , 2021 , 59 : 256 - 269 .

KRAG D N , ANDERSON S J , JULIAN T B , et al. Technical outcomes of sentinel-lymph-node resection and conventional axillary-lymph-node dissection in patients with clinically node-negative breast cancer: results from the NSABP B-32 randomised phase Ⅲ trial [J ] . Lancet Oncol , 2007 , 8 ( 10 ): 881 - 888 .

SAMIEI S , SIMONS J M , ENGELEN S M E , et al. Axillary pathologic complete response after neoadjuvant systemic therapy by breast cancer subtype in patients with initially clinically node-positive disease: a systematic review and meta-analysis [J ] . JAMA Surg , 2021 , 156 ( 6 ): e210891.

毕钊 , 陈鹏 , 邱鹏飞 , 等 . 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 . DOI: 10.19401/j.cnki.1007-3639.2023.04.006 http://doi.org/10.19401/j.cnki.1007-3639.2023.04.006

BI Z , CHEN P , QIU P F , et al. The analysis of axillary lymph nodes metastasis after neoadjuvant therapy in breast cancer [J ] . China Oncol , 2023 , 33 ( 4 ): 361 - 367 .

VAN HEMERT A K E , VAN LOEVEZIJN A A , BAAS M P D , et al. Omitting axillary lymph node dissection in breast cancer patients with extensive nodal disease and excellent response to primary systemic therapy using the MARI protocol [J ] . Breast , 2025 , 80 : 104411 .

DONKER M , STRAVER M E , WESSELING J , et al. Marking axillary lymph nodes with radioactive iodine seeds for axillary staging after neoadjuvant systemic treatment in breast cancer patients: the MARI procedure [J ] . Ann Surg , 2015 , 261 ( 2 ): 378 - 382 . DOI: 10.1097/SLA.0000000000000558 http://doi.org/10.1097/SLA.0000000000000558

VAN DER NOORDAA M M , VAN DUIJNHOVEN F H , STRAVER M E , et al. Major reduction in axillary lymph node dissections after neoadjuvant systemic therapy for node-positive breast cancer by combining PET/CT and the MARI procedure [J ] . Ann Surg Oncol , 2018 , 25 ( 6 ): 1512 - 1520 . DOI: 10.1245/s10434-018-6404-y http://doi.org/10.1245/s10434-018-6404-y

VAN LOEVEZIJN A A , VAN DER NOORDAA M E M , STOKKEL M P M , et al. Three-year follow-up of de-escalated axillary treatment after neoadjuvant systemic therapy in clinically node-positive breast cancer: the MARI-protocol [J ] . Breast Cancer Res Treat , 2022 , 193 ( 1 ): 37 - 48 .

ARAGÓN-SÁNCHEZ S , CIRUELOS-GIL E , LÓPEZ-MARÍN L , et al. Feasibility of targeted axillary dissection for de-escalation of surgical treatment after neoadjuvant chemotherapy in breast cancer [J ] . Surg Oncol , 2022 , 44 : 101823 .

WU S Y , LI J W , WANG Y J , et al. Clinical feasibility and oncological safety of non-radioactive targeted axillary dissection after neoadjuvant chemotherapy in biopsy-proven node-positive breast cancer: a prospective diagnostic and prognostic study [J ] . Int J Surg , 2023 , 109 ( 7 ): 1863 - 1870 .

CABıOĞLU N , KARANLıK H , YıLMAZ R , et al. Targeted axillary dissection reduces residual nodal disease in clinically node- positive breast cancer after neoadjuvant chemotherapy [J ] . World J Surg Oncol , 2024 , 22 ( 1 ): 178.

LAWS A , LEONARD S , VINCUILLA J , et al. Risk of surgical overtreatment in CN1 breast cancer patients who become ypN0 after neoadjuvant chemotherapy: SLNB versus TAD [J ] . Ann Surg Oncol , 2025 , 32 ( 3 ): 2023 - 2028 . DOI: 10.1245/s10434-024-16625-7 http://doi.org/10.1245/s10434-024-16625-7

SIMONS J M , VAN NIJNATTEN T J A , VAN DER POL C C , et al. Diagnostic accuracy of radioactive iodine seed placement in the axilla with sentinel lymph node biopsy after neoadjuvant chemotherapy in node-positive breast cancer [J ] . JAMA Surg , 2022 , 157 ( 11 ): 991 - 999 . DOI: 10.1001/jamasurg.2022.3907 http://doi.org/10.1001/jamasurg.2022.3907

VAN NIJNATTEN T J A , SIMONS J M , SMIDT M L , et al. A novel less-invasive approach for axillary staging after neoadjuvant chemotherapy in patients with axillary node-positive breast cancer by combining radioactive iodine seed localization in the axilla with the sentinel node procedure (RISAS): a Dutch prospective multicenter validation study [J ] . Clin Breast Cancer , 2017 , 17 ( 5 ): 399 - 402 . DOI: S1526-8209(17)30130-1 http://doi.org/S1526-8209(17)30130-1

BOUGHEY J C , YU H M , DUGAN C L , et al. Changes in surgical management of the axilla over 11 years-report on more than 1500 breast cancer patients treated with neoadjuvant chemotherapy on the prospective I-SPY2 trial [J ] . Ann Surg Oncol , 2023 , 30 ( 11 ): 6401 - 6410 .

HEIDINGER M , WEBER W P . Axillary surgery for breast cancer in 2024 [J ] . Cancers (Basel) , 2024 , 16 ( 9 ): 1623.

中国抗癌协会乳腺癌专业委员会 , 中华医学会肿瘤学分会乳腺肿瘤学组 . 中国抗癌协会乳腺癌诊治指南与规范(2024年版) [J ] . 中国癌症杂志 , 2023 , 33 ( 12 ): 1092 - 1187 . DOI: 10.19401/j.cnki.1007-3639.2023.12.004 http://doi.org/10.19401/j.cnki.1007-3639.2023.12.004

The Society of Breast Cancer China Anti-Cancer Association, Breast Oncology Group of the Oncology Branch of the Chinese Medical Association . Guidelines for breast cancer diagnosis and treatment by China Anti-cancer Association (2024 edition) [J ] . China Oncol , 2023 , 33 ( 12 ): 1092 - 1187 .

AMIN M B , EDGE S B , GREENE F L , et al. AJCC cancer staging manual [M ] . 8th ed. New York : Springer , 2017 : 589 - 636 .

LEE J , PARK S , BAE S J , et al. Micrometastases in axillary lymph nodes in breast cancer, post-neoadjuvant systemic therapy [J ] . Breast Cancer Res , 2024 , 26 ( 1 ): 120.

CABIOĞLU N , KARANLIK H , YILDIRIM N , et al. Favorable outcome with sentinel lymph node biopsy alone after neoadjuvant chemotherapy in clinically node positive breast cancer at diagnosis: Turkish multicentric NEOSENTI-TURK MF-18-02-study [J ] . Eur J Surg Oncol , 2021 , 47 ( 10 ): 2506 - 2514 . DOI: 10.1016/j.ejso.2021.06.024 http://doi.org/10.1016/j.ejso.2021.06.024

HOUVENAEGHEL G , COHEN M , RARO P , et al. Sentinel node involvement with or without completion axillary lymph node dissection: treatment and pathologic results of randomized SERC trial [J ] . NPJ Breast Cancer , 2021 , 7 ( 1 ): 133.

WONG S M , ALMANA N , CHOI J , et al. Prognostic significance of residual axillary nodal micrometastases and isolated tumor cells after neoadjuvant chemotherapy for breast cancer [J ] . Ann Surg Oncol , 2019 , 26 ( 11 ): 3502 - 3509 . DOI: 10.1245/s10434-019-07517-2 http://doi.org/10.1245/s10434-019-07517-2

MOO T A , EDELWEISS M , HAJIYEVA S , et al. Is low-volume disease in the sentinel node after neoadjuvant chemotherapy an indication for axillary dissection? [J ] . Ann Surg Oncol , 2018 , 25 ( 6 ): 1488 - 1494 .

CLASSE J M , LOAEC C , GIMBERGUES P , et al. Sentinel lymph node biopsy without axillary lymphadenectomy after neoadjuvant chemotherapy is accurate and safe for selected patients: the GANEA 2 study [J ] . Breast Cancer Res Treat . 2019 ;173 ( 2 ): 343 - 352 .

LIN S Q , VO N P , YEN Y C , et al. Outcomes of sentinel node biopsy for women with breast cancer after neoadjuvant therapy: systematic review and meta-analysis of real-world data [J ] . Ann Surg Oncol , 2022 , 29 ( 5 ): 3038 - 3049 .

ZAHWE M , GHZAIEL A , NAJIA A , et al. Performance of sentinel lymph node biopsy after neoadjuvant chemotherapy in clinically node-positive breast cancer patients: systematic review and meta-analysis [J ] . Int J Surg , 2025 , 111 ( 4 ): 3040 - 3050 .

FU J F , CHEN H L , YANG J , et al. Feasibility and accuracy of sentinel lymph node biopsy in clinically node-positive breast cancer after neoadjuvant chemotherapy: a meta-analysis [J ] . PLoS One , 2014 , 9 ( 9 ): e1 05316.

SAMIEI S , DE MOOIJ C M , LOBBES M B I , et al. Diagnostic performance of noninvasive imaging for assessment of axillary response after neoadjuvant systemic therapy in clinically node-positive breast cancer: a systematic review and meta-analysis [J ] . Ann Surg , 2021 , 273 ( 4 ): 694 - 700 . DOI: 10.1097/SLA.0000000000004356 http://doi.org/10.1097/SLA.0000000000004356

LUAN T , LI Y Q , WU Q W , et al. Value of quantitative SPECT/CT lymphoscintigraphy in improving sentinel lymph node biopsy in breast cancer [J ] . Breast J , 2022 , 2022 : 6483318 .

CHRISTIN O L , KUTEN J , EVEN-SAPIR E , et al. Node positive breast cancer: concordance between baseline PET/CT and sentinel node assessment after neoadjuvant therapy [J ] . Surg Oncol , 2019 , 30 : 1 - 5 . DOI: S0960-7404(19)30066-0 http://doi.org/S0960-7404(19)30066-0

BAE S J , CHUN J W , LEE S B , et al. Outcomes of sentinel node biopsy according to MRI response in an association with the subtypes in CN1-3 breast cancer after neoadjuvant systemic therapy, multicenter cohort study [J ] . Breast Cancer Res , 2024 , 26 ( 1 ): 66.

DI MICCO R , SANTURRO L , GASPARRI M L , et al. PET/MRI for staging the axilla in breast cancer: current evidence and the rationale for SNB vs PET/MRI trials [J ] . Cancers (Basel) , 2021 , 13 ( 14 ): 3571.

QUINLAN C , UYEDA J W . Patient-friendly summary of the ACR appropriateness criteria: monitoring response to neoadjuvant systemic therapy for breast cancer [J ] . J Am Coll Radiol , 2018 , 15 ( 7 ): e11.

LEINERT E , LUKAC S , SCHWENTNER L , et al. The use of axillary ultrasound (AUS) to assess the nodal status after neoadjuvant chemotherapy (NACT) in primary breast cancer patients [J ] . Surg Oncol , 2024 , 52 : 102016 .

LIU Y , WANG Y , FENG S W , et al. Axillary ultrasound after neoadjuvant therapy reduces the false-negative rate of sentinel lymph node biopsy in patients with cytologically node-positive breast cancer [J ] . Breast Cancer Res Treat , 2023 , 197 ( 3 ): 515 - 523 .

牛向阳 , 冯其贞 , 熊斌 . 各种示踪技术在乳腺癌前哨淋巴结的应用进展 [J ] . 临床医学进展 , 2024 , 14 ( 7 ): 870 - 876 .

NIU X Y , FENG Q Z , XIONG B . Application progress of various tracer techniques in sentinel lymph node of breast cancer [J ] . Adv Clin Med , 2024 , 14 ( 7 ): 870 - 876 .

董维露 , 蔡婷 , 许华宁 , 等 . 乳腺癌前哨淋巴结经皮淋巴管超声造影结合临床病理特征的Logistic回归分析 [J ] . 中华超声影像学杂志 , 2023 , 32 ( 12 ): 1083 - 1089 .

DONG W L , CAI T , XU H N , et al. Regression analysis of percutaneous lymphatic contrast-enhanced ultrasound combined with clinicopathological features in the diagnosis of sentinel lymph nodes in breast cancer [J ] . Chin J Ultrasonogr , 2023 , 32 ( 12 ): 1083 - 1089 .

ZHENG Y , SUN J , ZHU L , et al. Diagnosing sentinel lymph node metastasis of T1/T2 breast cancer with conventional ultrasound combined with double contrast-enhanced ultrasound: a preliminary study [J ] . Quant Imaging Med Surg , 2023 , 13 ( 6 ): 3451 - 3463 .

LI J , LI H , GUAN L , et al. The value of preoperative sentinel lymph node contrast-enhanced ultrasound for breast cancer: a large, multicenter trial [J ] . BMC Cancer , 2022 , 22 ( 1 ): 455.

HUANG C X , LUO J , SHAN Z , et al. The value of the improved percutaneous and intravenous contrast-enhanced ultrasound diagnostic classification in sentinel lymph nodes of breast cancer [J ] . Quant Imaging Med Surg , 2024 , 14 ( 3 ): 2391 - 2404 .

WU X F , TANG L N , HUANG W Q , et al. Contrast-enhanced ultrasonography and blue dye methods in detection of sentinel lymph nodes following neoadjuvant chemotherapy in initially node positive breast cancer [J ] . Arch Gynecol Obstet , 2020 , 302 ( 3 ): 685 - 692 . DOI: 10.1007/s00404-020-05646-8 http://doi.org/10.1007/s00404-020-05646-8

浏览量

182

下载量

CSCD

文章被引用时，请邮件提醒。

提交

工具集

关联资源

MRI预测乳腺癌淋巴结状态的研究进展及展望

早期乳腺癌局部治疗与全身治疗的进展与展望

乳腺癌新辅助治疗后腋窝淋巴结转移情况分析

血浆长链非编码RNA H19对乳腺癌新辅助治疗效果的预测价值

HER2阳性浸润性乳腺癌新辅助治疗反应的预测因子及治疗前后HER2状态变化的评估