Usefulness of Breast MRI for Safe Omission of Axillary Lymph Nodes Dissection in Sentinel Node-Positive Breast Cancer Patients

Background: Preoperative identification of patients with extensive lymph node metastasis (LNM) is important for safe omission of axillary lymph node dissection (ALND) in sentinel node (SN)-positive (SN+) breast cancer patients. Methods: We evaluated retrospectively the collected data of 758 breast cancer patients who underwent axillary surgery between 2008 and 2017, excluding those who received neoadjuvant chemotherapy. Results: Of the 758 patients, 607 were not suspicious to have LNM by axillary ultrasound (AUS-), but 38 suspicious cases were found by breast magnetic resonance imaging (MRI). Of 15 patients undergoing axillary fine needle biopsy (AFNA) due to second-look axillary ultrasound (AUS), 9 underwent ALND because of a positive AFNA (AFNA+). Among 81 (10.9%) patients undergoing ALND due to SN+ findings, 6 (7.4%) had extensive LNM (LNM ≥ 4). If MRI was not performed, among the 90 of 673 patients undergoing ALND who had SN+ findings, 12 (13.3%) had LNM ≥ 4. Conclusions: The proportion of cases with LNM ≥ 4 was reduced from 13.3% to 7.4% among patients undergoing SN biopsies combined with breast MRI. ALND might be omitted safely in SN+ cases according to detailed preoperative evaluations using additional breast MRI to ultrasound.

Early Results of Omitting Completion Axillary Lymph Node Dissection in Sentinel Lymph Node Metastasis-Positive Breast Cancer Patients

Background: We investigated the early results of omitting completion axillary lymph node dissection (ALND) for axillary node metastasis-negative (N0), sentinel node (SN) metastasis-positive breast cancer patients. Patients and Methods: 489 patients had invasive N0 breast cancer treated without completion ALND, regardless of their SN metastasis status. Analyses included the associations between the SN metastasis status, clinicopathological findings and recurrence, between recurrence and clinicopathological findings, and recurrence-free survival. Results: 430 patients were SN biopsy (SNB)-negative, and 59 were SNB-positive. The SNB-positive patients received significantly more potent adjuvant therapy than the SNB-negative patients. Median follow-up was 3.7 years, and the axillary node recurrence was seen in 6 patients (1.2%) and recurrence in 21 patients. The SN status showed no associations with the clinicopathological findings or recurrence. Univariate analysis showed recurrence was associated with absence of hormonal therapy, ER-negative, PgR-negative, HER2-positive or triple-negative (TNBC) disease, a tumor ≥2.1 cm and higher nuclear grade. Multivariate analysis showed recurrence was associated with absence of hormonal therapy and a tumor ≥2.1 cm. Cox proportional hazards model showed recurrence was extremely early in ER-negative and TNBC patients. Conclusion: Completion ALND can be skipped in N0 breast cancer patients even if they are SNB-positive, but adjuvant therapy is essential.

No Axillary Lymph Node Dissection in Breast Cancer Patients with Sentinel Lymph Node Micrometastasis

Follow-up data of a series of 75 breast cancer patients with sentinel node (SN) micrometastases only (between 0.2 and 2 mm) and favorable histopathological features of the primary tumor (well-differentiated, T1 tumors without lymphovascular invasion) who refused completion axillary lymph node dissection (ALND) or who were unsuitable for surgery were assessed in order to detect the rate of axillary recurrence after an adjuvant chemoand/or hormonal adjuvant treatment was given. The great majority of patients (81.3%) did not undergo ALND due to the existence of favorable histopathologic factors while the rest were equally distributed among over 75-year-old women (10.6%) and patients at a high surgical risk due to comorbid conditions (9.3%). Sixty-six patients (88%) underwent conservative treatment (lumpectomy followed by adjuvant breast radiotherapy) while the remaining nine patients (12%) had total mastectomy;72 out of 75 patients (96%) received some forms of adjuvant chemoand/or hormone-therapy. After a median follow-up of 38 months (range 12 - 84 months), nine out of 75 patients (12%) had a disease relapse, only one of them (1.3%) being affected by an axillary recurrence in the untreated axilla three years after primary surgery. On these grounds, completion ALND could be safely omitted in patients with SN micrometastasis and favorable histopathological characteristics of the primary neoplasm due to the very low rate of axillary recurrence with no detrimental effect on survival.

Efficacy and prognosis of mastoscopic axillary lymph node dissection for breast cancer:a systematic evaluation and meta-analysis

Objective:To systematically evaluate the efficacy and prognosis of breast lumpectomy axillary lymphatic dissection for the treatment of breast cancer.Methods:We use computer to search PubMed,The Cochrane Library,EMBASE,Web of Science,China Knowledge Network,Wanfang database,VIP database and CBM for randomized controlled trials(RCTs)of breast lumpectomy in axillary lymphatic dissection for breast cancer.The search time frame was from the database establishment to July 2021.Meta-analysis was performed using Revman 5.4.1 software after 2 investigators independently screened the literature,extracted information,and evaluated the risk of bias of the included studies.Results:A total of 20 RCTs including 2672 patients were included.Mastoscopic axillary lymph node dissection(MALND)was used in the trial group and conventional axillary lymph node dissection(CALND)was used in the control group.The results showed that the trial group was more effective in controlling bleeding volume[MD=-54.72,95%CI(-79.73,-29.71),P<0.00001],postoperative drainage[MD=-98.99,95%CI(-128.83,-69.15),P<0.00001],length of hospital stay[MD=-2.75,95%CI(-4.67,-0.83),P=0.005],and incidence rate of adverse reaction[RR=0.30,95%CI(0.19,0.45),P<0.00001]were superior to the control group,and the differences were statistically significant.Conclusions:Current evidence suggests that MALND can achieve better outcomes compared with CALND.It is more advantageous in controlling the bleeding volume,postoperative drainage,length of hospital stays,and incidence rate of adverse events.

Factors associated with levelⅢlymph nodes positive and survival analysis of its dissection in patients with breast cancer

Objective:Surgical resection remains the mainstream radical therapy in patients with breast cancer.Given that no consensus has been reached on the exact indication for levelⅢlymph node dissection,the aim of this study is to explore factors associated with levelⅢlymph nodes positive and survival analysis of its dissection in patients with breast cancer.Materials and methods:A retrospective study including 61 patients after levelⅠ-Ⅲdissection via a smaller incision of pectoralis major and 61 patients experiencing only levelⅠandⅡclearance was performed.Clinicopathological outcomes were compared initially and survival analysis was conducted subsequently.Results:No significant differences were presented in baseline and clinicopathological characteristics between the two groups.Ten(16.4%)patients’levelⅢnodes were proven positive after levelⅢdissection.Positive nodes in levelⅠandⅡlymph nodes over 9 was demonstrated as an independent predictor of levelⅢnodes positive(OR:200.75[95%CI:7.77e5187.19],p-0.001).Although the levelⅠ-Ⅲlymph node dissection group presented a seemingly better disease-free survival,statistical significance was not detected(p-0.21).Conclusions:This study revealed that having positive nodes in levelⅠandⅡlymph nodes over 9 was a risk factor of levelⅢlymph nodes positive.But levelⅢlymph node dissection does not offer definite survival benefit.

Axillary lymph node management in breast cancer with positive sentinel lymph node biopsy

The surgical treatment of localized breast cancer has become progressively less aggressive over the years.The management of the axillary lymph nodes has been modified by the introduction of sentinel lymph node biopsy. Axillary dissection can be avoided in patients with sentinel lymph node negative biopsies. Based on randomized trials data, it has been proposed that no lymph node dissection should be carried out even in certain patients with sentinel lymph node positive biopsies. This commentary discusses the basis of such recommendations and cautions against a general omission of lymph node dissection in breast cancer patients with positive sentinel lymph node biopsies. Instead, an individualized approach based on axillary tumor burden and biology of the cancer should be considered.

Analysis of factors related to non-sentinel lymph node metastasis in 296 sentinel lymph node-positive Chinese breast cancer patients

Objective: Axillary lymph node dissection(ALND) may be unnecessary in 20%–60% of breast cancer patients with sentinel lymph node(NSLN) metastasis. The aim of the present study was to review the medical records of Chinese patients with early-stage breast cancer and positive NSLN metastasis to identify clinicopathological characteristics as risk factors for non-NSLN metastasis.Methods: The medical records of 2008 early-stage breast cancer patients who received intraoperative sentinel lymph node biopsy(SLNB) between 2006 and 2016 were retrospectively reviewed. These patients were clinically and radiologically lymph nodenegative and had no prior history of receiving neoadjuvant chemotherapy or endocrinotherapy. The clinicopathological characteristics of patients with positive NSLN metastasis who underwent ALND were investigated.Results: In the present study, 296 patients with positive NSLN metastases underwent ALND. Positive non-NSLN metastases were confirmed in 95 patients(32.1%). On univariate analysis, ≥ 3 positive NSLN metastases(P <0.01), NSLN macrometastases(P =0.023), and lymphovascular invasion(P = 0.04) were associated with non-NSLN metastasis(P <0.05). In multivariate analysis, the number of positive SLNs was the most significant predictor of non-SLN metastasis. For patients with 0, 1, 2, or 3 associated risk factors, the non-SLN metastatic rates were 11.5%, 22.5%, 35.2%, and 73.1%, respectively.Conclusions: The number of positive NSLNs, NSLN macrometastases, and lymphovascular invasion were correlated with nonSLN metastasis. The number of positive SLNs was an independent predictor for non-NSLN metastasis. When 2 or 3 risk factors were present in one patient, the probability of non-NSLN was higher than that in the American College of Surgeons Oncology Group Z0011 trial(27.3%); thus, avoiding ALND should be considered carefully.

Locoregional treatment of early breast cancer with isolated tumor cells or micrometastases on sentinel lymph node biopsy

The advent of sentinel lymph-node technique has led to a shift in lymph-node staging,due to the emergence of new entities namely micrometastases(p N1mi) and isolated tumor cells [p N0(i+)].The prognostic significance of this low positivity in axillary lymph nodes is currently debated,as is,therefore its management.This article provides updates evidence-based medicine data to take into account for treatment decision-making in this setting,discussing the locoregional treatment in p N0(i+) and p N1 mi patients(completion axillary dissection,axillary irradiation with or without regional nodes irradiation,or observation),according to systemic treatment,with the goal to help physicians in their daily practice.

The Risk Factors of Lymphedema in Breast Cancer Patients Post Axillary Clearance

Introduction: Breast cancer is the number one malignancy affecting females in Saudi Arabia with a prevalence of 22.4%. Breast cancer incidence increases annually due to the aid of established screening programs, leading to the discovery of breast cancer in its early stages. Surgical treatment is an integral part of early breast cancer management to achieve local control. Axillary surgical interventions such sentinel lymph node biopsy (SLNB) and axillary lymph node clearance (ALND) aim to stage the axilla as an adjunct to the management of the primary breast tumor. In this paper, we reviewed female breast cancer patients aged 30 - 60 who underwent surgical treatment of SLNB and/or ALND with reporting the prevalence of lymphedema and other associated complications and risk factors. Methodology: A cross-sectional non-interventional study, with a sample size of 250 including breast cancer cases from 2016 to 2019 at National Guard Hospital (NGH) in Jeddah, Saudi Arabia. Results: A total of 253 breast cancer cases were included in this study, with a mean age of 53 years, 52.7% were postmenopausal and positive family history was present among 21% of cases. Further, 90.9% of the cases had unilateral disease. Staging was as follows: stage I 14.5%, stage II 45.2%, stage III 37.1%, and stage IV 3.2%. Mastectomy was done in 73.4% cases and lumpectomy was performed in 34.1% of cases. In addition, 93.3% of patients had SLNB and 49% of them were positive. Axillary dissection was performed in 69.6% of our patients. Radiotherapy and chemotherapy were given to 71.8% and 80.4% of cases respectively. Among the chemotherapy (chemo) recipients, 40.2% received adjuvant chemo, 54.5% received neoadjuvant chemo, and the remaining 5.3% received both. Further, the most prevalent complication was pain accounting for 42.1% of total complications, and the least prevalent was cellulitis 4%. Also, seroma developed in 18.3% cases, paresthesia noted in 5.6% of cases, winged scapula was reported as 2%, weakness and necrosis were seen in 6% and 13.1% of cases respectively. Axillary vein thrombosis and lymphangiosarcoma were reported in none of the patients (0%). Lymphoedema accounted for 16.1% of overall complications, 85% of the patients who developed lymphedema had undergone ALND, and 12.9% and 14.4% received radiotherapy and chemotherapy respectively. Lymphedema was observed in breast cancer stages as follows: stage I 1.2%, stage II 7.2%, and stage III 5.2%. Patients with body mass index (BMI) of 30 - 39 kg/m2 had 7.2% prevalence of lymphedema compared to other BMI groups. Overall mortality was 8.3%. Conclusion: The findings of our study suggest that the prevalence of lymphedema was higher in ALND patients with locally advanced tumors, and higher BMI, compared to patients with stage I breast cancer and low BMI. Further, the prevalence of lymphedema in patients who underwent ALND was significantly lower than those who were treated by lumpectomy 10.3% (p-value = 0.034) in comparison to mastectomy 19.3%.

The Initial Implementation of the Sentinel Lymph Node Biopsy (SLNB) for Breast Cancer Management in Malta

Over the past two decades, the sentinel lymph node biopsy (SLNB) based on sentinel node (SN) being the first lymph node that harbors metastases, revolutionized breast cancer management. SLNB presents much less morbidity when compared to radical axillary lymph node dissection (ALND) where all nodes are dissected irrespective of their metastatic involvement. The purpose of this study was to evaluate the effectiveness of SLNB by investigating whether the histological characteristics of the SNs identified using scintigraphy are predictive of the histological characteristics of the ALN basin. Methods: Fifty-five female breast cancer patients underwent lymphoscintigraphy and SLNB followed by ALND. The histological status of the SN/s was correlated to the histological status of the ALNs to determine whether the SN accurately stages the ALNs in breast cancer. Results: During surgery, SNs were successfully isolated in 52 out of 55 cases (94.5%) (range, 0 to 9). No SNs were identified in 3 cases (5.5%). Results demonstrate a significant association (p = 0.05) between the metastatic status of SNs and the corresponding ALNs in 42 out of 52 patients (80.8%), but with a high false-negative rate (FNR) of 37.5%. Conclusion: The findings of this study show that the sentinel node concept provides the benefits of SLNB in the majority of instances. However, further work is required in reducing the FNR. Once the effectiveness of SLNB as a staging technique is locally established, the need of ALND in SN-negative patients would be limited, thus improving the quality of life of Maltese breast cancer patients.

Accuracy of Ultrasound Examination of Loco-Regional Lymph Nodes in Breast Cancer Follow-Up and Its Role in the Axillary Surgical Management

Objective: Major international guidelines have not standardized the sequence of diagnostic examinations during the follow-up of a patient with a diagnosed breast cancer. The aim of this study is to investigate the accuracy of sonography in the diagnosis of loco-regional lymphatic recurrences in comparison to the core needle biopsy results. Materials and Methods: Among 6455 patients who were followed up with clinical examination, mammography and ultrasound between January 2004 and November 2011, 125 (1.93%) patients had to be investigated with a core needle biopsy of a sonographically suspicious loco-regional lymph node. Results: Among the whole series, a total of 142 ultrasound-guided core needle biopsies were performed. Follow-up for the primary tumor lasted for a median time of 6.1 years (range 1 - 27 years). Ultrasound of suspicious loco-regional lymph nodes showed a sensitivity of 89.5%, a specificity of 87.1% and a positive predictive value of 89.5%. Conclusions: In our experience, ultrasound of suspicious loco-regional lymph nodes showed good accuracy and it should be a part of the standard examinations performed during follow-up for breast cancer.

Advances in regional nodal management of early-stage breast cancer

With the continuous improvement of systemic treatment, reasonable local regional control of early-stage breast cancer can be translated into survival benefits. The optimization of regional nodal management in patients with limited sentinel lymph node(SLN) metastasis needs to be weighed by surgical complications, regional recurrence risk, and lymph node status, as well as other escalating treatment(systemic/radiotherapy) that may result from deescalating surgery. With the effective support and supplementation of systemic therapy and radiotherapy, the management of axillary surgery is developing in a de-escalating trend. The widespread application of neoadjuvant therapy has contributed to optimizing the management of patients with clinically node-negative/imaging nodepositive disease. In clinical practice, it is necessary to consider the residual tumor burden of regional lymph nodes when formulating the optimal irradiation fields in patients with limited positive SLN without axillary lymph node dissection. The combined application of genomic tests and American College of Surgeons Oncology Group 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 the era of sentinel lymph node biopsy(SLNB), the regional nodal management of breast cancer should adhere to the concept of “updating ideas, making bold assumptions, and carefully seeking proof”, make full use of the benefits of systemic therapy and radiotherapy to reduce the scope of surgery and complications, and expand the “net benefit” of efficacy and quality of life. This review discusses the optimization of regional nodal management in the era of SLNB, in order to provide reference information for clinicians.

Clinicopathological features,psychological status,and prognosis of 33 patients with occult breast cancer

BACKGROUND Occult breast cancer(OBC)has traditionally been considered to be a carcinoma of unknown primary origin with a favorable prognosis and can be treated as stage II-III breast cancer.Due to the small number of cases and limited clinical experience,treatments vary greatly around the world and no standardized treatment has yet been established.AIM To investigate the clinicopathological features,psychological status and prognostic features of patients with OBC.METHODS The clinicopathological data of 33 OBC patients diagnosed and treated in the Affiliated Hospital of Xuzhou Medical University and Xuzhou Central Hospital from November 2015 to November 2022 were retrospectively analyzed.The psychological status of OBC patients was evaluated by the Self-rating Anxiety Scale and Self-rating Depression Scale.Patients’emotions,stress perception and psychological resilience were evaluated by the Positive and Negative Affect Schedule,the Chinese Perceived Stress Scale,and the Connor-Davidson Resilience Scale(CD-RISC),respectively.Patient survival was calculated using the Kaplan-Meier method,and survival curves were plotted for analysis with the log-rank test.Univariate and multivariate survival analyses were performed using the Cox regression model.RESULTS The 33 OBC patients included 32 females and 1 male.Of the 33 patients,30(91%)had axillary tumors,3(9%)had a neck mass as the primary symptom;18(54.5%)had estrogen receptor-positive tumors,17(51.5%)had progesterone receptor-positive tumors,and 18(54.5%)had Her-2-positive tumors;24(72.7%)received surgical treatment,including 18 patients who underwent modified radical mastectomy,1 patient who underwent breast-conserving surgery plus axillary lymph node dissection(ALND),and 5 patients who underwent ALND alone;12 patients received preoperative neoadjuvant therapy.All 30 patients developed anxiety and depression,with low positive affect scores and high negative affect scores,accompanied by a high stress level and poor psychological resilience.There were no differences in the psychological status of patients according to age,body mass index,or menopausal status.The overall survival and disease-free survival(DFS)of all the patients were 83.3%and 55.7%,respectively.Univariate analysis demonstrated that the initial tumor site(P=0.021)and node stage(P=0.020)were factors that may affect patient prognosis.The 5-year DFS rate of OBC patients who received radiotherapy was greater(P<0.001),while the use of different surgical methods(P=0.687)had no statistically significant effect on patient outcomes.Multivariate analysis revealed that radiotherapy(P=0.031)was an independent prognostic factor.Receiving radiotherapy had a significant effect on the CD-RISC score(P=0.02).CONCLUSION OBC is a rare breast disease whose diagnosis and treatment are currently controversial.There was no significant difference in the efficacy of other less invasive surgical procedures compared to those of modified radical mastectomy.In addition,radiotherapy can significantly improve patient outcomes.We should pay attention to the psychological state of patients while they receive antitumor therapy.

Axillary Sentinel Lymph Node Biopsy for Breast Cancer and Melanoma Patients after Previous Axillary Surgery: A Systematic Review

Objective: Sentinel lymph node biopsy (SLNB) is a validated staging technique for breast carcinoma. Some women are exposed to have a second SLNB due to breast cancer recurrence or a second neoplasia (breast or other). Due to modified anatomy, it has been claimed that previous axillary surgery represents a contra-indication to SLNB. Our objective was to analyse the literature to assess if a second SLNB is to be recommended or not. Methods: For the present study, we performed a review of all published data during the last 10 years on patients with previous axilla surgery and second SLNB. Results: Our analysis shows that second SLNB is feasible in 70%. Extra-axillary SNs rate (31%) was higher after radical lymph node dissection (ALND) (60% - 84%) than after SLNB alone (14% - 65%). Follow-up and complementary ALND following negative and positive second SLNB shows that it is a reliable procedure. Conclusion: The review of literature confirms that SLNB is feasible after previous axillary dissection. Triple technique for SN mapping is the best examination to highlight modified lymphatic anatomy and shows definitively where SLNB must be performed. Surgery may be more demanding as patients may have more frequently extra-axillary SN only, like internal mammary nodes. ALND can be avoided when second SLNB harvests negative SNs. These conclusions should however be taken with caution because of the heterogeneity of publications regarding SLNB and surgical technique.

Towards optimal management of the axilla in the context of a positive sentinel node biopsy in early breast cancer

The sentinel lymph node biopsy(SLNB) was initially pioneered for staging melanoma in 1994 and it has been subsequently validated by several trials, and has become the new standard of care for patients with clinically node negative invasive breast cancer. The focussed examination of fewer lymph nodes in addition to improvements in histopathological and molecular analysis has increased the rate at which micrometastases and isolated tumour cells are identified. In this article we review the literature regarding the optimal management of the axilla when the SLNB is positive for metastatic disease based on level 1 evidence derived from randomised clinical trials.

A Comparison of Breast Surgeon and Nomogram-Generated Risk Predictions of Sentinel and Non-Sentinel Node Metastases

Memorial Sloan-Kettering Cancer Center (MSKCC) has developed 2 nomograms: the Sentinel Lymph Node Nomogram (SLNN), which is used to predict the likelihood of sentinel lymph node (SLN) metastases in patients with invasive breast cancer, and the Non-Sentinel Lymph Node Nomogram (NSLNN), which is used to predict the likelihood of residual axillary disease after a positive SLN biopsy. Our purpose was to compare the accuracy of MSKCC nomogram predictions with those made by breast surgeons. Two questionnaires were built with characteristics of two sets of 33 randomly selected patients from the MSKCC Sentinel Node Database. The first included only patients with invasive breast cancer, and the second included only patients with invasive breast cancer and positive SLN biopsy. 26 randomly selected Brazilian breast surgeons were asked about the probability of each patient in the first set having SLN metastases and each patient in the second set having additional non-SLN metastases. The predictions of the nomograms and breast surgeons were compared. There was no correlation between nomogram risk predictions and breast surgeon risk prediction estimates for either the SLNN or the NSLNN. The area under the receiver operating characteristics curves (AUCs) were 0.871 and 0.657 for SLNN and breast surgeons, respectively (p 0.0001), and 0.889 and 0.575 for the NSLNN and breast surgeons, respectively (p 0.0001). The nomograms were significantly more accurate as prediction tools than the risk predictions of breast surgeons in Brazil. This study demonstrates the potential utility of both nomograms in the decision-making process for patients with invasive breast cancer.

保乳术联合乳腔镜腋窝淋巴结清扫术治疗早期乳腺癌的效果

目的探讨保乳术联合乳腔镜腋窝淋巴结清扫术治疗早期乳腺癌的效果。方法选取2021年9月至2022年12月淄博市妇幼保健院乳腺甲状腺外科收治的66例早期乳腺癌患者作为研究对象,按照单双号分组法分为对照组和观察组,每组各33例。对照组行保乳术联合常规腋窝淋巴结清扫术,观察组行保乳术联合乳腔镜腋窝淋巴结清扫术。比较两组肩关节活动度、并发症总发生率、引流管留置时间及术后引流量。结果术后3个月,两组肩关节活动度均小于术前,但观察组大于对照组(P<0.05)。观察组并发症总发生率低于对照组(P<0.05)。观察组引流管留置时间短于对照组,术后引流量少于对照组(P<0.05)。结论保乳术联合乳腔镜腋窝淋巴结清扫术治疗早期乳腺癌,可减少对肩关节活动度的影响,降低并发症发生率,缩短引流管留置时间,减少术后引流量,值得临床推广。

前哨淋巴结活检与腋窝淋巴结清扫术在乳腺癌手术中的应用效果

目的探讨前哨淋巴结活检与腋窝淋巴结清扫术在乳腺癌手术中的应用效果。方法回顾性分析86例女性乳腺癌患者临床资料,将术中接受前哨淋巴结活检的43例患者设为观察组,将术中接受腋窝淋巴结清扫术治疗的43例患者设为对照组。比较2组手术情况、肩关节活动度、肩关节功能、疼痛程度、免疫功能及并发症。结果观察组术中出血量[(76.52±6.29)ml]少于对照组[(89.74±7.35)ml],手术时间[(62.35±6.25)min]、拔管时间[(4.35±0.49)d]及住院时间[(8.63±1.12)d]短于对照组[(69.74±6.48)min、(5.24±0.67)d、(10.39±1.35)d],有统计学差异(P<0.05)。观察组术后外旋[(76.24±5.73)°]、内旋[(74.14±5.82)°]、屈曲[(150.32±9.82)°]、外展[(137.52±9.43)°]及肩关节Neer评分[(86.32±6.15)分]高于对照组[(68.78±5.42)°、(67.06±5.49)°、(138.97±9.37)°、(122.37±9.26)°、(80.54±6.07)分],有统计学差异(P<0.05)。观察组术后d1、d3、d7时视觉模拟评分法(VAS)评分[(5.21±1.17)分、(3.15±0.46)分、(1.42±0.29)分]低于对照组[(6.87±1.22)分、(3.87±0.52)分、(2.04±0.32)分],有统计学差异(P<0.05)。观察组术后CD3^(+)[(65.28±6.19)%]、CD4^(+)[(43.76±4.28)%]、CD4^(+)/CD8^(+)[(1.90±0.29)]高于对照组[(60.14±6.05)%、(40.15±4.19)%、(1.49±0.28)],CD8^(+)[(23.04±2.25)%]低于对照组[(26.81±2.34)%],并发症发生率低于对照组,有统计学差异(P<0.05)。结论术中进行前哨淋巴结活检可减轻对乳腺癌患者的机体创伤,降低手术对肩关节功能的影响,且对免疫功能影响更小,并发症更少。

Targeted axillary dissection after neoadjuvant chemotherapy for highly selective patients with initial cN1 breast cancer:A single-center prospective trial

Background:Sentinel lymph node(SLN)biopsy is gradually accepted as the standard of care in breast cancer patients with down-staged axillary disease after neoadjuvant chemotherapy(NAC).However,it is still difficult to precisely define pre-NAC clinical node-positive(cN1)and post-NAC clinical node-negative(ycN0).This prospective single-center trial was designed to evaluate the feasibility and accuracy of standard targeted axillary dissection(TAD)after NAC in highly selective pre-NAC cN1 patients(not considering ultrasound-based axillary ycN staging).Methods:This prospective trial included patients with initial pre-NAC cT1-3N1M0 invasive breast cancer but with a rigorous definition of cN1 from the Affiliated Cancer Hospital of Zhengzhou University.When NAC was effective(including complete and partial responses)and preoperative axillary palpation was negative,preoperative ultrasound-based axillary staging was not considered,and all patients underwent TAD followed by axillary lymph node(LN)dissection.The detection rate(DR)and false-negative rate(FNR)of TAD were calculated.Results:A total of 82 patients were included,and 77 of them were eligible for data analysis.The DR for TAD was 94.8%(73/77).There were 26 patients with one abnormal LN at the time of diagnosis based on ultrasound,45 patients with two,and 2 patients with three.One patient had one TAD LN,four patients had two TAD LNs,and 68 patients had three or more TAD LNs.Preoperative axillary palpation yielded negative results for all 73 patients who successfully underwent TAD.Preoperative ultrasound-based ycN0 and ycN+conditions were detected for 52 and 21 cases,respectively.The FNR was 7.4%(2/27)for standard TAD(≥3 SLNs),which was lower than that of all successful TAD(≥1 SLN;10.0%,3/30).Conclusions:In rigorously defined pre-NAC cN1 breast cancer patients,standard TAD is feasible for those with negative axillary palpation after NAC,and FNR is also less than 10%.Registration:chictr.org.cn,ChiCTR2100049093.

含铂新辅助免疫治疗用于三阴性乳腺癌的临床探究

目的探究含铂新辅助免疫治疗三阴性乳腺癌的临床疗效及安全性。方法收集程序性死亡受体-1(PD-1)阳性的三阴性乳腺癌患者64例,将其随机分为对照组与观察组各32例。对照组在术前给予化学治疗[白蛋白紫杉醇+顺铂(TP)方案],观察组在对照组TP方案基础上联合使用PD-1抑制剂卡瑞丽珠单抗进行术前新辅助免疫治疗。新辅助免疫治疗完成后4周,按照手术适应证选择改良根治术或保乳术,并根据术中前哨淋巴结活组织检查的结果决定是否进行腋窝淋巴结清扫。比较2组患者的客观缓解率、疾病控制率、病理学完全缓解率、保乳率、腋窝淋巴结豁免率、T淋巴细胞亚群水平、乏氧诱导因子-1α水平、血管内皮生长因子水平以及不良反应发生率。结果经过6个周期的新辅助免疫化学治疗后,观察组的客观缓解率、病理学完全缓解率、CD4^(+)T淋巴细胞水平均高于对照组(P均<0.05);观察组的乏氧诱导因子-1α和血管内皮生长因子水平均低于对照组(P均<0.05)。虽然观察组的疾病控制率、保乳率和腋窝淋巴结豁免率也相对较高,但与对照组比较差异无统计学意义(P均>0.05)。2组不良反应发生率比较差异无统计学意义(P>0.05)。结论含铂新辅助免疫治疗用于三阴性乳腺癌的临床疗效较为可观,能降低患者肿瘤负荷,改善患者预后,且较安全。