对于淋巴结阳性乳腺癌术前新辅助化疗后的前哨淋巴结手术，研究数据已经非常充分。不过，关于该手术肿瘤学安全性结局数据的研究极少。
2020年8月10日，美国乳腺外科医师学会和美国肿瘤外科学会《肿瘤外科学报》在线发表梅奥医学中心的研究报告，对临床淋巴结阳性乳腺癌患者术前新辅助化疗后前哨淋巴结手术与腋窝淋巴结清扫的肿瘤结局进行了比较。
该单中心回顾研究对2009年1月～2019年10月梅奥医学中心经活检证实为术前新辅助化疗后进行腋窝手术的602例临床淋巴结阳性（cN1-3）乳腺癌患者手术类型和结局进行回顾分析。
结果，其中前哨淋巴结手术占52.3%，而且逐年递增：
2009～2012年：21.1%
2013～2014年：35.3%
2015～2019年：75.3%
52.5%的前哨淋巴结阳性患者未行腋窝淋巴结清扫。
腋窝淋巴结清扫±前哨淋巴结手术的比例逐年递减：
2009～2012年：97.2%
2013～2014年：83.3%
2015～2019年：57.2%
直接进行腋窝淋巴结清扫的287例患者淋巴结阳性比例为64.5%，而且逐年递增：
2009～2012年：55.6%
2013～2014年：69.7%
2015～2019年：75.9%
根据多因素分析，前哨淋巴结手术显著相关因素包括：
临床T分期较低（cT1-3与cT4相比）
临床N分期较低（cN1与cN2-3相比）
HER2阳性
中位随访34个月期间，区域复发17例：
腋窝淋巴结清扫：16/443例（3.61%）
前哨淋巴结手术：1/159例（0.63%）
2年无区域复发生存比例相似（P=0.10）
前哨淋巴结手术：99.1%
腋窝淋巴结清扫：96.4%
因此，该研究结果表明，对于临床淋巴结阳性乳腺癌术前新辅助化疗患者，前哨淋巴结手术已经日益普及。前哨淋巴结手术的选择基于临床因素和肿瘤生物学特征。被选择进行前哨淋巴结手术的患者超过一半避免了腋窝淋巴结清扫，淋巴结复发比例低，2年无区域复发生存比例相似。
Ann Surg Oncol. 2020 Aug 10. Online ahead of print.
Oncologic Outcomes of Sentinel Lymph Node Surgery After Neoadjuvant Chemotherapy for Node-Positive Breast Cancer.
Mara A. Piltin, Tanya L. Hoskin, Courtney N. Day, John Davis Jr., Judy C. Boughey.
Mayo Clinic, Rochester, MN, USA.
BACKGROUND: Sentinel lymph node (SLN) surgery after neoadjuvant chemotherapy (NAC) has been well studied. However, outcomes data addressing the oncologic safety of this technique are sparse. This study aimed to evaluate use of SLN surgery versus axillary lymph node dissection (ALND) for clinically node-positive patients treated with NAC and to report outcomes.
METHODS: The study identified patients at the authors' institution with biopsy proven clinically node-positive (cN1-cN3) breast cancer undergoing axillary surgery after NAC from 2009 to 2019. Practice patterns and outcomes were evaluated.
RESULTS: Of 602 patients, 52.3% underwent SLN surgery. Use of SLN surgery increased significantly over time, reaching 75.3% during 2015-2019. For 52.5% of the patients who had an SLN identified, ALND was not used. Use of ALND (±SLN surgery) decreased from 100% in 2009 to 57.2% in 2015-2019. The nodal positivity rate of patients who proceeded directly to ALND was 64.5% (185/287), increasing significantly over time. Factors significantly associated with performing SLN surgery on multivariable analysis were lower presenting clinical T category, lower presenting clinical N category (cN1 vs cN2-3) and HER2-positive status. During the median 34-month follow-up period, 17 regional recurrences were observed (16/443 with ALND; 1/159 with SLN surgery alone), for a 2-year freedom-from-regional-recurrence rate of 99.1% among the SLN surgery patients and 96.4% among the ALND patients (p=0.10).
CONCLUSIONS: For cN1-3 breast cancer treated with NAC, SLN surgery has been incorporated into clinical practice at the authors' institution. In this study, selection for SLN surgery was based on clinical factors and tumor biology. More than half of the patients who were selected for SLN surgery were spared ALND, with a low nodal failure rate and no recurrence-free survival disadvantage at 2 years.
DOI: 10.1245/s10434-020-08900-0
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