《中国临床肿瘤学会乳腺癌诊疗指南2018.V1》外科问题解读

Surgical management of breast cancer in guidelines of Chinese Society of Clinical Oncology

新辅助化疗是局部晚期乳腺癌或炎性乳腺癌的规范疗法,可以使肿瘤降期以利于手术或将不可能手术转变为可以手术,一般应按照既定化疗方案周期数(6~8个周期)内最大疗效的原则进行。新辅助化疗后的保乳与常规保乳术后局部复发率间差异无统计学意义,新辅助化疗后保乳切除范围应根据肿瘤初始状况、分子亚型、肿瘤化疗后退缩模式等综合考虑,切缘阴性是基本原则。新辅助化疗后的前哨淋巴结活检(SLNB)争议较多,对cN0病人新辅助化疗前后均可行SLNB,对于c N1-cN0病人可以考虑在双示踪剂、增加淋巴结检出数目、免疫组化病理学检查、应用标记夹等方法有效降低假阴性率(FNR)后行SLNB。Ⅳ期乳腺癌原发灶切除是否改善生存尚存争议,手术应在全身治疗有效的基础上进行,现阶段转移灶手术的主要目的是改善病人生存质量。

Neoadjuvant chemotherapy is standard treatment for locally advanced breast cancer or inflammatory breast cancer to downstage tumor and make the inoperable breast cancer operable, it is recommended to deliver all planned treatment （the standard 4 to 8 cycles） to achieve better prognosis. There were no significant differences in the local recurrence when breast conserving surgery （BCS） is given after neoadjuvant chemotherapy（NACT） or primarily for early breast cancer. Multiple factors such as primary tumor, molecular subtypes, tumor response should be considered to the extent of BCS after NACT. A negative margin is a standard for BCS following neoadjuvant therapy.There was some controversy regarding sentinel lymph node biopsy（SLNB） after NACT. SLNB can be carried out before or after NACT in case of the clinically negative axilla（cN0） initially. For a patient who downstaged to negative（cNl-cN0） undergo SLNB, the false negative rate can be improved by using dual tracer and IHC staining, removing more sentinel nodes, marking axillary node with clip.The impact of primary tumor resection （PTR） on survival is still controversial in stage 1V breast cancer. Generally, the primary treatment approach for metastatic breast cancer is systemic therapy, with the consideration of surgery after effective systemic treatment. Surgery of distant sites of recurrence may be indicated as needed for improving quality of life.