1~2枚前哨淋巴结阳性早期乳腺癌患者治疗策略降阶梯新理念

New concept of de-escalation management strategy in breast cancer patients with 1-2 positive sentinel lymph nodes

随着乳腺癌前哨淋巴结活检(sentinel lymph node biopsy,SLNB)的广泛应用,乳腺癌全身治疗与区域处理理念也随之得到优化。SLNB时代,1~2枚前哨淋巴结(sentinel lymph node,SLN)阳性患者豁免腋窝淋巴结清扫(axillary lymph nodedissection,ALND)比例逐渐增加,腋窝区域处理降阶梯理念降低了患者术后并发症的发生率,改善了患者的生活质量;多基因检测与Z0011/AMAROS标准的联合应用,使得1~2枚SLN阳性豁免ALND患者能够精准接受多基因检测,不仅能使腋窝区域处理降阶梯,而且也能让全身辅助治疗降阶梯,从而使患者获得真正意义上的个体化双降阶梯治疗;1~2枚SLN阳性豁免ALND患者区域淋巴结放疗靶区的确定应充分评估腋窝残留肿瘤负荷,并结合临床复发风险因素来优化。SLNB时代,全身治疗和放疗的综合应用,将作为有力手段,合理缩小手术范围并减少并发症,充分扩大疗效与患者生活质量的“净获益”。本文就1~2枚SLN阳性早期乳腺癌患者治疗策略降阶梯理念优化进行综述。

In the era of sentinel lymph node biopsy(SLNB),the axillary management concept that 1-2 positive sentinel lymph node(SLN)could safely omit axillary lymph node dissection(ALND)are gradually being accepted by more and more patients.The omission of ALND is safe with no difference in regional recurrence in early breast cancer patients with limited SLN involvement.With the effective support and supplement of systemic therapy and radiotherapy,the management concept of axilla surgery is developing in a de-escalating trend.The combined application of multi-gene tests and ACSOG Z0011/AMAROS criteria could provide patients with a better strategy of dual de-escalation treatment,which includes the de-escalation of both axillary surgery and systemic treatment.In clinical practice,it is necessary to combine the residual tumor burden of regional lymph nodes to formulate the optimal irradiation fields in patients with 1-2 positive SLNs without ALND.In the era of SLNB,we can make full use of the benefits of systemic therapy and radiotherapy to reasonably reduce the scope of surgery and complications,therefore expand the"net benefit"of efficacy and quality of life.This paper reviewed the optimization of the de-escalation strategy concept for systemic and regional management in patients with 1-2 positive SLNs.