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中华普通外科学文献(电子版)

中华普通外科学文献(电子版) ›› 2020, Vol. 14 ›› Issue (03) : 230 -234. doi: 10.3877/cma.j.issn.1674-0793.2020.03.016

所属专题： 文献；

论著

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
崔世恩1, 凌飞海1,†(), 黄志华1, 马士辉1   
  1. 1. 528403　中山市人民医院乳腺外科
  • 收稿日期:2019-12-19 出版日期:2020-06-01
  • 通信作者: 凌飞海

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

Shien Cui1, Feihai Ling1,†(), Zhihua Huang1, Shihui Ma1   

  1. 1. Department of Breast Surgery, Zhongshan City People's Hospital, Zhongshan 528403, China
  • Received:2019-12-19 Published:2020-06-01
  • Corresponding author: Feihai Ling
  • About author:
    Corresponding author: Ling Feihai, Email:
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崔世恩, 凌飞海, 黄志华, 马士辉. 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[J]. 中华普通外科学文献(电子版), 2020, 14(03): 230-234.

Shien Cui, Feihai Ling, Zhihua Huang, Shihui Ma. Influence of neoadjuvant chemotherapy on axillary lymph node dissection in axillary lymph node positive, ER-negative/HER2-positive breast cancer[J]. Chinese Archives of General Surgery(Electronic Edition), 2020, 14(03): 230-234.

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 0.395a 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)
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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