目的 评估乳腺癌新辅助化疗(neoadjuvant chemotherapy,NAC)后通过体格检查、乳腺彩超及乳腺磁共振成像(magnetic resonance imaging,MRI)等方法判断腋窝淋巴结(axillary lymph node,ALN)为(clinical node negative)cN0患者,分析其腋窝前哨淋巴结(axillary sentinel lymph node biopsy,ASLNB)的检出成功率、准确率及假阴性率,从而探讨NAC后ASLNB的可行性。方法 回顾性分析2013年8月—2016年7月收治于肿瘤外科符合入组标准的乳腺癌患者共74例,根据患者术前体格检查、乳腺彩超及乳腺MRI平扫及增强检查,将NAC后患者分为3组,A组:体格检查及乳腺彩超为cN0,共55例;B组:体格检查、乳腺彩超及乳腺MRI平扫及增强为cN0,共50例;C组:体格检查、乳腺彩超和乳腺MRI平扫+增强均为cN+,共24例。结果 A组:临床缓解率为74.3%,ASLNB成功率为100%,准确率为92.7%,假阴性率(false negative rate,FNR)9.7%;B组:临床缓解率为 67.6%,ASLNB成功率为100%,准确率为94.0%,FNR为7.8%。C组患者24例全部直接行腋窝淋巴结清扫(axillary lymph node dissection,ALND)。A、B两组患者ASLNB的FNR比较,差异无统计学意义(P>0.05)。结论 NAC前ALN评估为cN+,经NAC后通过体格检查、乳腺超声评估ALN转变为cN0的乳腺癌患者,可以通过行ASLNB代替ALND;增加MRI检查,可以进一步降低FNR,MRI可能在判断NAC后乳腺癌ALN状态方面具有一定的应用价值。
Objective To evaluate the detection rate,accuracy rate,and false negative rate of axillary sentinel lymph node biopsy (SLNB) after neoadjuvant chemistry (NAC) in axillary lymph node (ALN) clinical node negative (cN0) patients examined by physical examination,breast ultrasound,and breast magnetic resonance imaging (MRI),and discuss the feasibility of ASLNB after NAC.Methods Seventy-four cases of breast cancer admitted to the Department of Surgery Oncology,Provincial Clinical Institute,Fujian Medical University from August 2013 to July 2016 were enrolled in the study for retrospective analysis.All of the patients receiving NAC were divided into three groups according to the results of physical examination,breast ultrasound,and MRI.There were 55 cN0 cases judged by physical examination and breast ultrasound (group A),50 cyN0 cases by additional breast MRI (group B),and 24 clinical node positive (cN+) cases by all the three examination techniques (group C).Results In group A,the clinical remission rate of ALN was 74.3%,and the successful rate,accuracy rate,and false negative rate of ASLNB were 100%,92.7%,and 9.7%,respectively.In group B,the above indicators were 67.6%,100%,94.0%,and 7.8%,respectively.The cN+ patients in group C were given axillary lymph node dissection (ALND).The false negative rate of ASLNB had no significant difference (P>0.05) between group A and group B.Conclusion SLNB can replace ALND for the patients whose ALN transformed to cN0 from cN+ after NAC by physical examination and breast ultrasound.The false negative rate can be further decreased with additional MRI.MRI can be used to judge ALN in breast cancer patients after NAC.
[1] Fisher B,Bryant J,Wolmark N,et al.Effect of preoperative chemotherapy on the outcome of women with operable breast cancer[J].J Clin Oncol,1998,16(8):2672-2785.
[2] Bear HD.Neoadjuvant chemotherapy for operable breast cancer:individualizing locoregional and systemic therapy[J].Surg Oncol Clin N Am,2010,19(3):607-626.
[3] Geng C,Chen X,Pan X.The feasibility and accuracy of sentinel lymph node biopsy in initially clinically node-negative breast cancer after neoadjuvant chemotherapy:a systematic review and meta-analysis[J].PLoS One,2016,11(9):e0162605.
[4] Mamounas EP,Brown A,Anderson S,et al.Sentinel node biopsy after neoadjuvant chemotherapy in breast cancer:results from National Surgical Adjuvant Breast and Bowel Project Protocol B-27[J].J Clin Oncol,2005,23(12):2694-2702.
[5] Boughey JC.Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer[J].JAMA,2013,310(14):1455-1461.
[6] Boughey JC,Ballman KV,Hunt KK,et al.Axillary ultrasound after neoadjuvant chemotherapy and its impact on sentinel lymph node surgery:results from the American College of Surgeons Oncology Group Z1071 Trial (Alliance)[J].J Clin Oncol,2015,33(30):3386-3393.
[7] Gradishar WJ,A.B.O.Balassanian R.Breast Cancer Version 2.2015[J].J Natl Compr Canc Netw,2015,33(3):448-475.
[8] Zetterlund LH,Frisell J,Zouzos A,et al.Swedish prospective multicenter trial evaluating sentinel lymph node biopsy after neoadjuvant systemic therapy in clinically node-positive breast cancer[J].Breast Cancer Res Treat,2017,163(1):103-110.
[9] Boileau JF,Poirier B,Basik M,et al.Sentinel node biopsy after neoadjuvant chemotherapy in biopsy-proven node-positive breast cancer:the SN FNAC study[J].J Clin Oncol,2015,33(3):258-264.
[10] Kuehn T,Bauerfeind I,Fehm T,et al.Sentinel-lymph-node biopsy in patients with breast cancer before and after neoadjuvant chemotherapy (SENTINA):a prospective,multicentre cohort study[J].Lancet Oncol,2013,14(7):609-618.
[11] Croshaw R,Shapiro-Wright H,Svensson E,et al.Accuracy of clinical examination,digital mammogram,ultrasound,and MRI in determining postneoadjuvant pathologic tumor response in operable breast cancer patients[J].Ann Surg Oncol,2011,18(11):3160-3163.
[12] Liu S,Ren R,Chen Z,et al.Diffusion-weighted imaging in assessing pathological response of tumor in breast cancer subtype to neoadjuvant chemotherapy[J].J Magn Reson Imaging,2015,42(3):779-787.
