【原】乳房切除后腋窝治疗方式九年变迁

　　对于接受乳房切除的前哨淋巴结阳性乳腺癌患者，最佳的腋窝治疗方式仍然存在争议。

　　2019年4月25日，施普林格·自然《乳腺癌研究与治疗》在线发表美国德克萨斯大学MD安德森癌症中心、哈佛大学医学院布莱根医院和波士顿妇女医院、达纳法伯癌症研究所的研究报告，通过大样本人群数据库，分析了2006～2014年前哨淋巴结阳性乳腺癌患者乳房切除后腋窝治疗方式的变迁。

　　该研究首先对全国癌症数据库（NCDB）进行检索，纳入2006～2014年接受乳房切除治疗、术前未接受新辅助化疗、临床分期肿瘤大小不超过≤5厘米（T1-2）淋巴结未扪及（N0）1～2个前哨淋巴结阳性乳腺癌患者数据，腋窝治疗方式包括前哨淋巴结切除、腋窝淋巴结清扫、乳房切除后放疗、腋窝淋巴结清扫＋乳房切除后放疗，随后对腋窝治疗方式的变迁和患者特征进行分析。

　　结果，符合研究标准的患者共计12190例，腋窝淋巴结清扫随着其他方式的增加而减少。

　　2006年、2014年相比，不同治疗方式的患者比例：

• 前哨淋巴结切除：34%、37%

• 腋窝淋巴结清扫：47%、23%

• 乳房切除后放疗：8%、27%

• 腋窝淋巴结清扫＋乳房切除后放疗：11%、13%

　　单纯接受前哨淋巴结切除的患者特征：

• 年龄较大（平均60.6岁，P<0.01）

• 合并症多（评分>2分，P<0.01）

• 肿瘤较小（平均2.1cm，P<0.01）

• 分化良好（P<0.01）

• 激素受体阳性（P<0.01）

• HER2阴性（P<0.01）

• 未浸润淋巴血管（P<0.01）

• 一个前哨淋巴结阳性（P<0.001）

• 微转移（P<0.001）

• 社区治疗中心（P<0.001）

　　因此，该研究结果表明，对于接受乳房切除的1～2个前哨淋巴结阳性乳腺癌患者，随着时间的推移，腋窝淋巴结清扫逐渐减少，前哨淋巴结切除、乳房切除后放疗逐渐增加。由于最近的临床研究此类患者亚组样本量不足，故将来的研究应该针对这些患者。

Breast Cancer Res Treat. 2019 Apr 25.

Evolution in practice patterns of axillary management following mastectomy in patients with 1-2 positive sentinel nodes.

Anna Weiss, Heather Lin, Gildy V. Babiera, Isabelle Bedrosian, Simona F. Shaitelman, Yu Shen, Henry M. Kuerer, Elizabeth A. Mittendorf, Abigail S. Caudle, Kelly K. Hunt, Rosa F. Hwang.

The University of Texas MD Anderson Cancer Center, Houston, USA; Brigham and Women's Hospital, Boston, USA; Dana-Farber/Brigham and Women's Cancer Center, Boston, USA.

PURPOSE: The optimal management of breast cancer patients with a positive sentinel lymph node (SLN) who undergo mastectomy remains controversial. This study aimed to describe treatment patterns of patients with positive SLNs who undergo mastectomy using a large population-based database.

METHODS: The NCDB was queried for cT1-2N0 breast cancer patients treated with mastectomy between 2006 and 2014 who had 1-2 positive SLNs. Patients receiving neoadjuvant chemotherapy were excluded. Axillary management included SLN dissection (SLND) alone, axillary lymph node dissection (ALND), post-mastectomy radiation (PMRT) alone, and ALND+PMRT. Trends of axillary management and patient characteristics were examined.

RESULTS: Among 12,190 patients who met study criteria, the use of ALND dropped with a corresponding increase in other approaches. In 2006, 34% of patients had SLND alone, 47% ALND, 8% PMRT and 11% ALND+PMRT. By 2014, 37% had SLND, 23% ALND, 27% PMRT and 13% ALND+PMRT. Patients who underwent SLND alone were older (mean 60.6 years) with more comorbidities (Charlson-Deyo score>2), smaller primary tumors (mean 2.1 cm), well-differentiated histology, hormone receptor-positive, HER2-negative tumors, without lymphovascular invasion (all P values<0.01). Treatment with SLND alone was more likely if patients had only one positive SLN (P<0.001) or micrometastatic disease (P<0.001), and were treated at community centers compared with academic centers (P<0.001).

CONCLUSIONS: The management of breast cancer patients undergoing mastectomy with positive SLNs has evolved over time with decreased use of ALND and increased use of radiation. Some patient subsets are underrepresented in recent clinical trials, and therefore, future trials should focus on these patients.

KEYWORDS: Axillary management after mastectomy PMRT rates ALND rates Pathologic positive nodal disease after mastectomy AMAROS

DOI: 10.1007/s10549-019-05243-7