梅奥：三阴性乳腺癌全身治疗进展

　　三阴性乳腺癌的雌激素受体、孕激素受体、人类表皮生长因子受体HER2均为阴性，对内分泌治疗和HER2靶向治疗无效，除了手术和放疗等局部治疗，几十年来全身治疗主要依靠化疗。目前，三阴性乳腺癌与其他乳腺癌相比，复发率和死亡率仍然较高。对于可以手术的三阴性乳腺癌，改善患者结局的努力集中于术后全身治疗升级，以及转变为术前全身治疗后根据疗效决定术后全身治疗方法。随着对三阴性乳腺癌肿瘤生物学特征的深入了解，不断发现具有特定分子特征的患者亚群，从而测试并批准针对该疾病的多种新型靶向治疗方法。此外，随着药物开发的进步，抗体缀合药物获得批准，这正在重新定义乳腺癌的分类方案。

　　2023年5月30日，国际四大医学期刊之一、英国医学会《英国医学杂志》正刊发表美国梅奥医学中心的长篇综述：三阴性乳腺癌全身治疗进展。全文共计15页，参考文献达107篇。

　　美国梅奥医学中心从1864年（清朝同治三年）建立于明尼苏达州罗切斯特小镇的私人诊所开始，如今已发展为全球规模最大的私营医疗教学科研集团，拥有自己的医院、医学院、研究院、出版社，虽然床位数和患者数不及中国最大医院的十分之一，但是员工数和营业收入超出数倍，罗切斯特小镇也发展为明尼苏达州第三大城市，人口十万左右，其中三分之一为梅奥员工，超过七成人口为梅奥提供服务，随着IBM公司撤离，梅奥已成为罗切斯特乃至整个明尼苏达州的支柱产业，业务从明尼苏达州已拓展至全国以及中南美洲和亚洲。2020年，梅奥宣布启用全新中文名称：妙佑（既佛系，又莆田系，还有一些萌）。

　　该综述侧重于三阴性乳腺癌现代管理，尤其关注可手术早期乳腺癌治疗最新进展，并概述晚期乳腺癌治疗领域最新进展。该综述还讨论了术前免疫治疗批准带来的临床挑战和亟待解决问题，并分享了对于那些缺乏证据的临床问题有哪些解决方法。最后，该综述对未来进行了展望，强调了根据生物学标志物调整术前治疗强度、术后对术前治疗效果评估的改进、复发的早期诊断和检测、晚期三阴性乳腺癌相关研究领域的挑战和机遇。

乳腺癌术前全身治疗示意图

可手术三阴性乳腺癌术前全身治疗方法

晚期三阴性乳腺癌全身治疗方法

可手术三阴性乳腺癌根据术前疗效决定术后治疗

BMJ. 2023 May 30;381:e071674. IF: 93.333

Advances in systemic therapies for triple negative breast cancer.

Leon-Ferre RA, Goetz MP.

Mayo Clinic, Rochester, MN, USA.

Triple negative breast cancer (TNBC) continues to be the subtype of breast cancer with the highest rates of recurrence and mortality. The lack of expression of targetable proteins such as the estrogen receptor and absence of HER2 amplification have made relying on cytotoxic chemotherapy necessary for decades. In the operable setting, efforts to improve outcomes have focused on escalation of systemic therapy and a shift toward preoperative delivery followed by a response adapted approach to postoperative systemic therapy. An improved understanding of tumor biology has resulted in the identification of subsets of patients with specific molecular features, leading to testing and approval of multiple new targeted therapies for this disease. Furthermore, advances in drug development have led to the approval of antibody-drug conjugates that are redefining classification schemes for breast cancer. This review focuses on the modern management of TNBC, with particular focus on recent updates in the treatment of operable disease, and an overview of the most recent promising advances in the therapeutic landscape of metastatic disease. It discusses the practical challenges and unanswered questions resulting from the approval of neoadjuvant immunotherapy and shares an approach in the clinic on topics for which evidence is lacking. In addition, it provides a glimpse into the future, highlighting challenges and opportunities for biomarker based right-sizing of preoperative therapy, refining evaluation of response to preoperative therapy after surgery, early diagnosis and detection of relapse, and areas of needed research for metastatic TNBC.

PMID: 37253507

DOI: 10.1136/bmj-2022-071674