新辅助治疗对雌激素受体低表达/人类表皮生长因子受体2阳性乳腺癌腋窝淋巴结状态的影响

doi:10.3877/cma.j.issn.1674-0793.2020.03.016

目的

评估人类表皮生长因子受体2（HER2）阳性乳腺癌患者接受不同新辅助治疗（NAC）方案后腋窝淋巴结病理缓解情况及影响因素。

方法

纳入2010年11月至2015年12月中山市人民医院收治的100例HER2阳性、Ⅱa~Ⅲc期乳腺癌患者，在NAC前通过触诊和细针穿刺（FNA）评估腋窝淋巴结状态。所有患者接受4~6个周期的PCrb（紫杉醇175 mg/m²和卡铂AUC=6，每3周），部分患者接受联合曲妥珠单抗（6 mg/kg每3周，首剂8 mg/kg）。

结果

62例通过FNA确定为腋窝淋巴结阳性（A组），38例通过FNA或触诊确定为腋窝淋巴结阴性（B组）。其中A组总体腋窝淋巴结病理阴性率（pNNR）为53.2％，B组为71.1％。雌激素受体（ER）低表达/HER2阳性患者的pNNR最高，A组为81.0％，B组86.7％。多因素分析显示，联合曲妥珠单抗和ER状态是预测HER2阳性乳腺癌pNNR的独立因素。

结论

对于治疗前腋窝淋巴结阳性的乳腺癌患者，如果NAC联合靶向治疗后前哨淋巴结阴性，ER低表达/HER2阳性就不需要腋窝淋巴结清扫。

关键词: 乳腺肿瘤, 新辅助化疗, 淋巴结切除术, 前哨淋巴结活组织检查

Objective

To evaluate the pathological response and influencing factors of axillary lymph nodes in patients with ER-negative/HER2-positive breast cancer after neoadjuvant therapy.

Methods

From November 2010 to December 2015, one hundred patients with HER2-positive, stage Ⅱa-Ⅲc breast cancer in Zhongshan City People’s Hospital were enrolled and evaluated for axillary status by palpation and fine needle aspiration (FNA) before neoadjuvant chemotherapy (NAC). All patients received 4-6 cycles of PCrb (paclitaxel 175 mg/m² and carboplatin AUC=6 every 3 weeks), and some patients combined with trastuzumab (6 mg/kg every 3 weeks).

Results

Sixty-two patients were confirmed positive axillary lymph nodes by FNA (group A), and thirty-eight patients were considered negative axillary lymph nodes by FNA or palpation (group B). The axillary lymph node pathological negative node rate (pNNR) was 53.2% in group A and 71.1% in group B. The pNNR of ER-negative/HER2-positive was the highest (81.0% in group A and 86.7% in group B). In multivariate analysis, combined trastuzumab and ER status were independent factors predicting pNNR in HER2-positive breast cancer.

Conclusion

For breast cancer patients with positive lymph nodes before NAC, the ER-negative/ HER2-positive subtype is a potential type of patients with negative sentinel lymph nodes that do not require axillary lymph node dissection after NAC combined with targeted therapy.

Key words: Breast neoplasms, Neoadjuvant chemotherapy, Lymph node excision, Sentinel lymph node biopsy

表1 两组人类表皮生长因子受体2阳性乳腺癌患者一般情况的比较

项目		A组	B组	统计值	P值
例数		62	38	?	?
年龄(岁，±s)		51.2±10.4	50.4±9.8	0.395^a	0.540
NAC方案[例(%)]		?	?	0.006	0.939
?	PCrbH	38(61.3)	23(60.5)	?	?
?	PCrb	24(38.7)	15(39.5)	?	?
月经状态[例(%)]		?	?	0.035	0.876
?	绝经前	32(51.6)	19(50.0)	?	?
?	绝经后	30(48.4)	19(50.0)	?	?
T分期[例(%)]		?	?	0.085	0.770
?	1	4(6.5)	1(2.6)	?	?
?	2	19(30.6)	12(31.6)	?	?
?	3	9(14.5)	7(18.4)	?	?
?	4	30(48.4)	18(47.4)	?	?
N分期[例(%)]		?	?	2.272	0.132
?	0	0(0)	33(86.8)	?	?
?	1	46(74.2)	0(0)	?	?
?	2	6(9.7)	0(0)	?	?
?	3	10(16.1)	5(13.2)	?	?
ER状态[例(%)]		?	?	1.073	0.300
?	高表达	26(41.9)	12(31.6)	?	?
?	低表达	36(58.1)	26(68.4)	?	?
PR状态[例(%)]		?	?	1.073	0.300
?	高表达	26(41.9)	12(31.6)	?	?
?	低表达	36(58.1)	26(68.4)	?	?
手术类型[例(%)]		?	?	0.723	0.395
?	切除术	58(93.5)	37(97.4)	?	?
?	保乳术	4(6.5)	1(2.6)	?	?

表1 两组人类表皮生长因子受体2阳性乳腺癌患者一般情况的比较

项目		A组	B组	统计值	P值
例数		62	38	?	?
年龄(岁，±s)		51.2±10.4	50.4±9.8	0.395^a	0.540
NAC方案[例(%)]		?	?	0.006	0.939
?	PCrbH	38(61.3)	23(60.5)	?	?
?	PCrb	24(38.7)	15(39.5)	?	?
月经状态[例(%)]		?	?	0.035	0.876
?	绝经前	32(51.6)	19(50.0)	?	?
?	绝经后	30(48.4)	19(50.0)	?	?
T分期[例(%)]		?	?	0.085	0.770
?	1	4(6.5)	1(2.6)	?	?
?	2	19(30.6)	12(31.6)	?	?
?	3	9(14.5)	7(18.4)	?	?
?	4	30(48.4)	18(47.4)	?	?
N分期[例(%)]		?	?	2.272	0.132
?	0	0(0)	33(86.8)	?	?
?	1	46(74.2)	0(0)	?	?
?	2	6(9.7)	0(0)	?	?
?	3	10(16.1)	5(13.2)	?	?
ER状态[例(%)]		?	?	1.073	0.300
?	高表达	26(41.9)	12(31.6)	?	?
?	低表达	36(58.1)	26(68.4)	?	?
PR状态[例(%)]		?	?	1.073	0.300
?	高表达	26(41.9)	12(31.6)	?	?
?	低表达	36(58.1)	26(68.4)	?	?
手术类型[例(%)]		?	?	0.723	0.395
?	切除术	58(93.5)	37(97.4)	?	?
?	保乳术	4(6.5)	1(2.6)	?	?

图1 腋窝pNNR多因素分析

表2 新辅助治疗后不同亚型腋窝淋巴缓解情况［例(%)］

项目			A组(62例)				B组(38例)
项目			pNNR	非-pNNR	χ²值	P值	pNNR	非-pNNR	χ²值	P值
NAC方案			?	?	2.102	0.147	?	?	3.783	0.051
?	PCrbH		23(60.5)	15(39.5)	?	?	19(82.6)	4(17.4)	?	?
?	PCrb		10(41.7)	14(58.3)	?	?	8(53.3)	7(46.7)	?	?
月经状态			?	?	0.069	0.793	?	?	0.487	0.485
?	绝经前		16(50.0)	16(50.0)	?	?	12(63.2)	7(36.8)	?	?
?	绝经后		16(53.3)	14(46.7)	?	?	14(73.7)	5(26.3)	?	?
T分期			?	?	0.160	0.690	?	?	0.433	0.510
?	1		2(50.0)	2(50.0)	?	?	1(100.0)	0(0.0)	?	?
?	2		11(57.9)	8(42.1)	?	?	7(58.3)	5(41.7)	?	?
?	3		5(55.6)	4(44.4)	?	?	5(71.4)	2(28.6)	?	?
?	4		15(50.0)	15(50.0)	?	?	13(72.2)	5(27.7)	?	?
ER状态			?	?	3.921	0.048	?	?	1.380	0.240
?	高表达		10(38.5)	16(61.5)	?	?	7(58.3)	5(41.7)	?	?
?	低表达		23(63.9)	13(36.1)	?	?	20(76.9)	6(23.1)	?	?
PR状态			?	?	0.900	0.343	?	?	3.779	0.052
?	高表达		12(46.2)	14(53.8)	?	?	6(50.0)	6(50.0)	?	?
?	低表达		21(58.3)	15(41.7)	?	?	21(80.8)	5(19.2)	?	?
NAC方案+ER状态			?	?	?	?	?	?	?	?
?	PCrbH		?	?	8.197	0.004	?	?	0.494	0.482
?	?	ER高表达	6(35.3)	11(64.7)	?	?	6(75.0)	2(25.0)	?	?
?	?	ER低表达	17(81.0)	4(19.0)	?	?	13(86.7)	2(13.3)	?	?
?	PCrb		?	?	0.411	0.521	?	?	0.024	0.876
?	?	ER高表达	3(33.3)	6(66.7)	?	?	2(50.0)	2(50.0)	?	?
?	?	ER低表达	7(46.7)	8(53.3)	?	?	6(54.5)	5(45.5)	?	?

表2 新辅助治疗后不同亚型腋窝淋巴缓解情况［例(%)］

项目			A组(62例)				B组(38例)
项目			pNNR	非-pNNR	χ²值	P值	pNNR	非-pNNR	χ²值	P值
NAC方案			?	?	2.102	0.147	?	?	3.783	0.051
?	PCrbH		23(60.5)	15(39.5)	?	?	19(82.6)	4(17.4)	?	?
?	PCrb		10(41.7)	14(58.3)	?	?	8(53.3)	7(46.7)	?	?
月经状态			?	?	0.069	0.793	?	?	0.487	0.485
?	绝经前		16(50.0)	16(50.0)	?	?	12(63.2)	7(36.8)	?	?
?	绝经后		16(53.3)	14(46.7)	?	?	14(73.7)	5(26.3)	?	?
T分期			?	?	0.160	0.690	?	?	0.433	0.510
?	1		2(50.0)	2(50.0)	?	?	1(100.0)	0(0.0)	?	?
?	2		11(57.9)	8(42.1)	?	?	7(58.3)	5(41.7)	?	?
?	3		5(55.6)	4(44.4)	?	?	5(71.4)	2(28.6)	?	?
?	4		15(50.0)	15(50.0)	?	?	13(72.2)	5(27.7)	?	?
ER状态			?	?	3.921	0.048	?	?	1.380	0.240
?	高表达		10(38.5)	16(61.5)	?	?	7(58.3)	5(41.7)	?	?
?	低表达		23(63.9)	13(36.1)	?	?	20(76.9)	6(23.1)	?	?
PR状态			?	?	0.900	0.343	?	?	3.779	0.052
?	高表达		12(46.2)	14(53.8)	?	?	6(50.0)	6(50.0)	?	?
?	低表达		21(58.3)	15(41.7)	?	?	21(80.8)	5(19.2)	?	?
NAC方案+ER状态			?	?	?	?	?	?	?	?
?	PCrbH		?	?	8.197	0.004	?	?	0.494	0.482
?	?	ER高表达	6(35.3)	11(64.7)	?	?	6(75.0)	2(25.0)	?	?
?	?	ER低表达	17(81.0)	4(19.0)	?	?	13(86.7)	2(13.3)	?	?
?	PCrb		?	?	0.411	0.521	?	?	0.024	0.876
?	?	ER高表达	3(33.3)	6(66.7)	?	?	2(50.0)	2(50.0)	?	?
?	?	ER低表达	7(46.7)	8(53.3)	?	?	6(54.5)	5(45.5)	?	?

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Influence of neoadjuvant chemotherapy on axillary lymph node dissection in axillary lymph node positive, ER-negative/HER2-positive breast cancer

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Influence of neoadjuvant chemotherapy on axillary lymph node dissection in axillary lymph node positive, ER-negative/HER2-positive breast cancer