乳腺癌新辅助化疗后内乳区前哨淋巴结活检研究

Internal mammary sentinel lymph node biopsy in breast cancer patients after neoadjuvant chemotherapy

目的:新辅助化疗(neoadjuvant chemotherapy,NAC)目前已成为局部晚期乳腺癌患者的标准治疗模式。本研究旨在评估乳腺癌患者在NAC后接受内乳区前哨淋巴结活检(internal mammary sentinel lymph node biopsy,IMSLNB)的临床获益。方法:回顾性分析2014年4月—2018年4月山东大学附属山东省肿瘤医院乳腺病中心收治的202例接受NAC的原发性乳腺癌患者的临床资料并进行统计分析,入组患者术前均采用"新型注射技术"注射核素示踪剂。术前哨位淋巴结显像和(或)术中γ探测仪发现内乳区前哨淋巴结(internal mammary sentinel lymph node,IMSLN)显像者行经肋间IMSLNB。根据目前的指南评估NAC后接受IMSLNB的临床获益。结果:入组202例患者,NAC后IMSLN显像率为34.2%(69/202),且与临床肿瘤分期相关(P=0.017),IMSLN显像患者中,临床淋巴结阴性和临床淋巴结阳性(clinical lymph node-positive,cN^+)患者分别占11.6%(8/69)和88.4%(61/69)。NAC后IMSLNB的成功率为98.6%(68/69),IMSLN的检出率为33.7%(68/202),转移率为11.8%(8/68),8例IMSLN转移患者,术后淋巴结分期发生了改变,其中1例患者不伴腋窝淋巴结(axillary lymph node,ALN)转移(pN_0至pN_(1b)),2例伴1～3枚ALN转移(pN_(1a)至pN_(1c)),4例伴4～9枚ALN转移(pN_(2a)至pN_(3b)),1例伴≥10枚ALN转移(pN_(3a)至pN_(3b)),术后病理学分期也发生了改变(0期至ⅠB期,ⅡA/ⅢA期至ⅢC期),这8例IMSLN转移患者术后均接受了内乳区放疗(internal mammary node irradiation,IMNI)。结论:NAC后IMSLN有显像的患者,尤其是cN^+患者,NAC后应接受IMSLNB,以期获得完整的淋巴结分期。IMSLNB能够进一步完善淋巴结病理完全缓解的定义并指导IMNI。

Background and purpose:Neoadjuvant chemotherapy(NAC)has become the standard treatment mode for locally advanced breast cancer patients.This study aimed to evaluate the clinical benefits of internal mammary sentinel lymph node biopsy(IMSLNB)in patients with breast cancer who underwent NAC.Methods:From Apr.2014 to Apr.2018,202 patients with primary breast cancer who underwent operation after NAC were included in this study.All patients received radiotracer injection with modified injection technology.IMSLNB was performed on patients with internal mammary sentinel lymph node(IMSLN)visualization.Results:Among the 202 patients,the visualization rate of IMSLN was 34.2%(69/202),and it was 11.6%(8/69)and88.4%(61/69)among patients with clinical node-negative and clinical lymph node-positive(cN+)disease,respectively.Furthermore,the success rate of IMSLNB was 98.6%(68/69).The detection rate of IMSLN was 33.7%(68/202),and the metastasis rate was11.8%(8/68).One of the 8 patients with IMSLN metastasis was not associated with axillary lymph node(ALN)metastasis(N0to N1b),2 patients with 1-3 ALN metastases(N1a to N1c),4 patients with 4-9 ALN metastases(N2a to N3b),1 case with≥10 ALN metastases(N3a to N3b),and the postoperative pathological stage also changed(0 stage toⅠB stage,ⅡA/ⅢA stage toⅢC stage).These 8 cases of IMSLN metastases received internal mammary node irradiation(IMNI)after operation.Conclusion:Patients with visualization of IMSLN should receive IMSLNB after NAC,especially for patients with cN+disease,in order to complete lymph nodal staging.IMSLNB could further improve the definition of nodal pathologic complete response and guide the IMNI.