Axillary surgery for patients with breast cancer (BC) in 2024 is becoming increasingly specific, moving away from the previous ‘one size fits all’ radical approach. The goal is to spare morbidity whilst maintaining oncologic safety. In the upfront surgery setting, a first landmark randomized controlled trial (RCT) on the omission of any surgical axillary staging in patients with unremarkable clinical examination and axillary ultrasound showed non-inferiority to sentinel lymph node (SLN) biopsy (SLNB). The study population consisted of 87.8% postmenopausal patients with estrogen receptor-positive, human epidermal growth factor receptor 2-negative BC. Patients with clinically node-negative breast cancer and up to two positive SLNs can safely be spared axillary dissection (ALND) even in the context of mastectomy or extranodal extension. In patients enrolled in the TAXIS trial, adjuvant systemic treatment was shown to be similar with or without ALND despite the loss of staging information. After neoadjuvant chemotherapy (NACT), targeted lymph node removal with or without SLNB showed a lower false-negative rate to determine nodal pathological complete response (pCR) compared to SLNB alone. However, oncologic outcomes do not appear to differ in patients with nodal pCR determined by either one of the two concepts, according to a recently published global, retrospective, real-world study. Real-world studies generally have a lower level of evidence than RCTs, but they are feasible quickly and with a large sample size. Another global real-world study provides evidence that even patients with residual isolated tumor cells can be safely spared from ALND. In general, few indications for ALND remain. Three randomized controlled trials are ongoing for patients with clinically node-positive BC in the upfront surgery setting and residual disease after NACT. Pending the results of these trials, ALND remains indicated in these patients.
2024年，针对乳腺癌患者的腋窝手术正日益趋向个体化，逐渐摒弃了以往“一刀切”的根治性模式。其目标是在保证肿瘤学安全性的同时，降低手术相关并发症。在初始手术情境下，一项具有里程碑意义的随机对照试验首次表明，对于临床检查和腋窝超声均无异常的患者，省略所有腋窝手术分期与进行前哨淋巴结活检相比，疗效非劣效。该研究人群主要为绝经后、雌激素受体阳性、人表皮生长因子受体2阴性的乳腺癌患者。对于临床淋巴结阴性且前哨淋巴结阳性不超过2枚的患者，即使接受乳房切除术或存在淋巴结外侵犯，也可安全地避免腋窝淋巴结清扫。TAXIS试验数据显示，无论是否进行腋窝淋巴结清扫，患者的辅助全身治疗方案相似，尽管这可能导致分期信息的缺失。在新辅助化疗后，与单纯前哨淋巴结活检相比，靶向淋巴结切除联合或不联合前哨淋巴结活检在判定淋巴结病理完全缓解方面具有更低的假阴性率。然而，根据近期发表的一项全球性、回顾性、真实世界研究，无论采用上述哪种方法判定淋巴结病理完全缓解，患者的肿瘤学结局似乎并无差异。真实世界研究通常证据等级低于随机对照试验，但具有快速实施和大样本量的优势。另一项全球真实世界研究证实，即使是存在残留孤立肿瘤细胞的患者，也可安全避免腋窝淋巴结清扫。总体而言，腋窝淋巴结清扫的适应症已显著减少。目前有三项随机对照试验正在进行中，分别针对初始手术时临床淋巴结阳性以及新辅助化疗后仍有残留病灶的患者。在这些试验结果公布前，上述患者仍需进行腋窝淋巴结清扫。
肿瘤(癌症)患者之家