乳腺癌前哨淋巴结活检的最佳时机

　　对于早期乳腺癌临床腋窝淋巴结阴性术前新辅助化疗患者，前哨淋巴结活检最佳时机尚不明确。

　　2019年1月21日，日本乳腺癌学会《乳腺癌》在线发表济南大学山东省医学科学院医学与生命科学学院、山东大学附属山东省肿瘤医院王永胜等学者的研究报告，探讨了不同分子亚型早期乳腺癌临床腋窝淋巴结阴性术前新辅助化疗患者前哨淋巴结活检的最佳时机。

　　该研究于2008年4月～2018年4月入组乳腺癌新辅助化疗后患者592例。对新辅助化疗前后临床淋巴结阴性患者进行前哨淋巴结活检，如果前哨淋巴结阳性，进行腋窝淋巴结清扫。对于临床淋巴结阳性患者，腋窝手术由医生决定。

　　结果，新辅助化疗后腋窝乳房病理完全缓解104例（17.6%）

• HR阳性HER2阴性：19例（6.9%）

• 三阴性：36例（33.3%，P<0.001）

• HER2阳性＋靶向疗法：32例（32.3%，P<0.001）

• HER2阳性－靶向疗法：17例（15.3%，P<0.001）

　　临床淋巴结阳性患者525例，其中新辅助化疗后腋窝病理完全缓解108例（34.5%）

• HR阳性HER2阴性：51例（21.2%）

• 三阴性：50例（53.2%，P<0.001）

• HER2阳性＋靶向疗法：51例（58.6%，P<0.001）

• HER2阳性－靶向疗法：29例（28.2%，P=0.031）

　　临床淋巴结阴性患者67例，其中前哨淋巴结阳性13例（19.4%）

• HR阳性HER2阴性：9例（28.1%）

• HR阴性HER2阴性：2例（13.3%）

• HR阴性HER2阳性：2例（10.0%）

　　因此，该研究结果表明，病理完全缓解率与分子亚型显著相关。结合不同分子亚型乳腺癌临床淋巴结阳性患者的腋窝淋巴结病理完全缓解率、Z0011研究和AMAROS研究临床淋巴结阴性患者良好的局部区域控制，对于临床淋巴结阴性患者，三阴性/HER2阳性亚型与HR阳性HER2阴性亚型相比，新辅助化疗→前哨淋巴结活检的获益较大。为了减少腋窝淋巴结清扫，建议对于临床淋巴结阴性患者：

• HR阳性HER2阴性亚型：前哨淋巴结活检→新辅助化疗

• 三阴性/HER2阳性亚型：新辅助化疗→前哨淋巴结活检

Breast Cancer. 2019 Jan 21. [Epub ahead of print]

Neoadjuvant chemotherapy and timing of sentinel lymph node biopsy in different molecular subtypes of breast cancer with clinically negative axilla.

Zhao Bi, Jingjing Liu, Peng Chen, Yanbing Liu, Tong Zhao, Chunjian Wang, Zhaopeng Zhang, Xiao Sun, Pengfei Qiu, Binbin Cong, Xianrang Song, Yongsheng Wang.

University of Jinan-Shandong Academy of Medical Sciences, Jinan, China; Shandong Cancer Hospital Affiliated to Shandong University, Jinan, China; Qingdao Municipal Hospital, Qingdao, China.

PURPOSE: This study aims to determine the optimal time to perform sentinel lymph node biopsy (SLNB) for patients with clinically node-negative (cN0) disease following neoadjuvant chemotherapy (NAC).

METHOD: From April 2008 to April 2018, 592 patients with breast cancer underwent after NAC were included in this study. Patients with cN0 before and ycN0 disease after NAC received SLNB and axillary lymph node dissection (ALND) in case of positive sentinel lymph nodes (SLNs). For patients with clinically node-positive (cN+) disease, the axillary surgery is based on the doctor's decision.

RESULT: In general, 17.6% (104/592) of patients achieved total pathologic complete response (pCR), which was 6.9%, 33.3%, 32.3% and 15.3%, respectively, among patients with hormone receptor (HR) positive/ human epidermal growth factor receptor-2 (HER-2) negative (HR+/HER2-) subtype, triple-negative (TN) subtype, HER-2 positive (HER2+) subtype with and without targeted therapy (p < 0.001). Among the 525 cN+ patients, the axillary nodal pCR (apCR) rate was 34.5%, and the apCR rate was significantly higher in patients with HER2+ (58.6% with and 28.2% without targeted therapy respectively) and TN subtype (53.2%) than that in patients with HR+/HER2-subtype (21.2%, p < 0.001). Among the 67 cN0 patients, the positive rate of SLNs was 19.4% (13/67), which was 28.1% (9/32), 13.3% (2/15) and 10.0% (2/20), respectively, among patients with HR+/HER2-, TN and HER2 + subtypes.

CONCLUSION: The pCR rates were significantly related to molecular subtype. Combining the apCR rates in different molecular subtypes of cN+ patients and the excellent locoregional control of AOSOG Z0011 and AMAROS trials in cN0 patients, it would be preferable to perform SLNB prior to NAC for cN0 patients with HR+/HER2- subtype, and SLNB after NAC for those cN0 patients with TN and HER2+ subtype to increase the chance of avoiding ALND. Among cN0 patients, TN and HER2 + subtypes would benefit more from axillary de-escalating surgery after NAC than HR+/HER2- subtype.

KEYWORDS: Breast cancer Neoadjuvant chemotherapy Molecular subtype Pathologic complete response Sentinel lymph node biopsy

DOI: 10.1007/s12282-018-00934-3