目的：对于满足ACOSOG Z0011入组条件的1~2枚前哨淋巴结（sentinel lymph node, SLN）转移病人,分析影响其未行腋窝淋巴结清扫（axillary lymph node dissection, ALND）的相关因素及其对预后的价值。方法：回顾性分析2012年1月至2019年8月在我院乳腺疾病诊治中心接受手术的cT1-2N0、计划接受保乳和放疗的浸润性乳腺癌病人,分析SLN 1~2枚转移病人未行进一步ALND的影响因素,并评估该治疗方式对预后的影响。结果：用优势比（odds ratio,OR）以及95%CI表示。结果：共有161例病人入组,SLN活检（SLNB）组（未行ALND）和ALND组病人分别为78和83例。ALND组11（13.3%）例发现有非SLN转移,4（4.8%）例有3枚ALN转移。单因素及多因素分析均提示,手术年份是行ALND的影响因素（P<0.001）。手术年份近的病人,更多选择不行ALND。SLNB组和ALND组分别有11例（14.1%）和6例（3.6%）病人未接受辅助化疗。单因素分析发现术后辅助化疗与年龄（P<0.001）、月经状态（P=0.016）和ALN手术（P=0.018）相关。多因素分析显示,影响化疗的独立因素为年龄(P<0.001)。中位随访42.0个月,发现SLNB组1例（1.3%）ALN复发,ALND组无ALN复发。结论：对于SLN 1~2枚转移且满足ACOSOG Z0011试验入组条件的病人,可以不行ALND。ALND手术与预后的关系,有待进一步研究证实。
Objective To analyze the factors influencing breast cancer patients with 1-2 positive sentinel lymph nodes which meets ACOSGO Z0011 criteria without further axillary lymph node dissection (ALND) and their prognosis. Methods Patients with cT1-2N0 invasive breast cancer received breast conserving surgery and radiotherapy were enrolled retrospectively in Comprehensive Breast Health Center, Rujin Hospital between January 2012 and August 2019. Factors which influenced not to receive further ALND in patients with 1-2 positive sentinel lymph node and its association with prognosis were analyzed. Results were listed as odds ratio and 95% confidence interval. Results A total of 161 patients were studied, including 78 patients without ALND in the SLNB group and 83 patients in the ALND group. There were 11 (13.3%) patients with non-SLN metastasis and 4 (4.8%) patients with 3 axillary lymph node (ALN) metastasis in the ALND group. Both univariate and multivariate analysis found that surgical-year was associated with ALND (P<0.001). Patients in more recent surgical-year were received less ALND. Eleven (14.1%) and 6 (3.6%) patients in the SLNB and ALND groups had no further adjuvant chemotherapy, respectively. Univariate analysis showed that age (P<0.001), menopausal status (P=0.016), and ALN surgery(P=0.018) were related with adjuvant chemotherapy. Multivariate analysis showed that only age was independently related with chemotherapy(P<0.001). With a median follow up of 42.0 months, ALN recurrence was found only 1 (1.3%) patient in the SLNB group and none in the ALND group. Conclusions Patients with 1-2 positive sentinel nodes who met the eligible criteria of ACOSOG Z0011 trial could be treated without ALND. The association of ALND with long-term survival deserves further evaluation.
[1] Lyman GH, Somerfield MR, Bosserman LD, et al.Sentinel lymph node biopsy for patients with early-stage breast cancer: American Society of Clinical Oncology Clinical Practice Guideline Update[J]. J Clin Oncol,2017, 35(5):561-564.
[2] Giuliano AE, Hunt KK, Ballman KV, et al.Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: A rando-mized clinical trial[J]. JAMA,2011,305(6):569-575.
[3] Harbeck N, Gnant M.Breast cancer[J]. Lancet,2017,389(10074):1134-1150.
[4] Krag DN, Anderson SJ, Julian TB, et al.Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial[J]. Lancet Oncol,2010,11(10):927-933.
[5] Giuliano AE, Ballman KV, McCall L, et al. Effect of axillary dissection vs no axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis: The ACOSOG Z0011 (Alliance) randomized clinical trial[J]. JAMA,2017,318(10):918-926.
[6] Galimberti V, Cole BF, Viale G, et al.Axillary dissection versus no axillary dissection in patients with breast cancer and sentinel-node micrometastases (IBCSG 23-01): 10-year follow-up of a randomised, controlled phase 3 trial[J]. Lancet Oncol,2018,19(10):1385-1393.
[7] Yi M, Kuerer HM, Mittendorf EA, et al.Impact of the American College of Surgeons Oncology Group Z0011 criteria applied to a contemporary patient population[J]. J Am Coll Surg,2013,216(1):105-113.
[8] Chung A, Gangi A, Mirocha J, et al.Applicability of the ACOSOG Z0011 criteria in women with high-risk node-positive breast cancer undergoing breast conserving surgery[J]. Ann Surg Oncol,2015,22(4):1128-1132.
[9] Dengel LT, van Zee KJ, King TA, et al. Axillary dissection can be avoided in the majority of clinically node-negative patients undergoing breast-conserving therapy[J]. Ann Surg Oncol,2014,21(1):22-27.
[10] Delpech Y, Bricou A, Lousquy R, et al.The exportability of the ACOSOG Z0011 criteria for omitting axillary lymph node dissection after positive sentinel lymph node biopsy findings: a multicenter study[J]. Ann Surg Oncol,2013,20(8):2556-2561.
[11] Howard DH, Soulos PR, Chagpar AB, et al.Contrary to conventional wisdom, physicians abandoned a breast cancer treatment after a trial concluded it was ineffective[J]. Health Aff (Millwood),2016,35(7):1309-1315.
[12] Poodt IGM, Spronk PER, Vugts G, et al.Trends on axillary surgery in nondistant metastatic breast cancer patients treated between 2011 and 2015: a Dutch population-based study in the ACOSOG-Z0011 and AMAROS era[J]. Ann Surg,2018,268(6):1084-1090.
[13] Liang Y, Chen X, Zhan W, et al.Can clinically node-negative breast cancer patients with suspicious axillary lymph nodes at ultrasound but negative fine-needle aspiration be approached as having node-negative disease?[J] Ann Surg Oncol,2017,24(7):1874-1880.
[14] Curigliano G, Burstein HJ, Winer EP, et al.De-escalating and escalating treatments for early-stage breast cancer: the St. Gallen International Expert Consensus Conference on the primary therapy of early breast cancer 2017[J]. Ann Oncol,2017,28(8):1700-1712.
