新辅助化疗后乳腺癌局部区域的分期评估和治疗的降阶梯策略

Staging and de-escalating treatment for locoregional area of breast cancer after neoadjuvant chemotherapy

近年来,新辅助化疗(NAC)作为局部晚期乳腺癌患者的标准治疗模式,给予不具有手术指征的患者手术机会,给有保留乳房需求的乳房切除患者保留乳房手术机会。另外NAC亦可给予腋窝区域降期以豁免腋窝淋巴结清扫。随着乳腺癌分子分型的不断精确,NAC的疗效不断提高,但是仍需要根据原发灶及腋窝局部区域的肿瘤负荷及首次NAC的疗效,不断完善后续局部区域治疗方式,进行个体化精准治疗,为患者带来更高的生活质量及生存获益。基于乳腺癌局部区域的精确评估使NAC后乳腺癌局部区域的最佳治疗方式选择突破了以往的局面,针对原发灶及腋窝局部区域NAC后降期的患者后续是否可以降阶梯治疗(如豁免淋巴结活组织检查、清扫、放射治疗)目前尚无定论。本文将梳理最新的临床研究,总结NAC后局部区域(包括乳腺原发灶以及腋窝区域)的分期评估和外科、放射治疗方式选择的最新进展,为临床医师处理此类问题提供依据。

In recent years,neoadjuvant chemotherapy(NAC),as a standard treatment for patients with locally advanced breast cancer,has made inoperable patients operable,and has given the opportunity of breast conserving surgery to patients with indication for breast resection.In addition,NAC can downstage axillary region,leading to the exemption of axillary lymph node dissection.With more precise molecular subtyping of breast cancer,the efficacy of NAC has been continuously improved.However,it is still necessary to improve the local treatment after NAC and carry out precise individualized treatment according to the tumor burden of primary tumor and locoregional area of the axilla and the effectiveness of the first NAC,so as to bring patients higher quality of life and more survival benefits.Based on the accurate assessment of locoregional areas of breast cancer,the optimal treatment for locoregional areas of breast cancer after NAC violates the previous view.There are some controversies on whether the patients with downstaged breast lesions and axilla can be treated with de-escalating strategy after NAC(such as exemption from lymph node biopsy,dissection,radiotherapy).This paper reviewed the latest clinical studies and summarized the optimal staging evaluation and the selection of surgical and radiotherapy in locoregional areas including primary breast lesions and axillary areas after NAC,in order to provide evidences for clinicians in dealing with such cases.