腋窝淋巴结和乳房内侧淋巴结（内乳淋巴结）作为乳腺癌淋巴结引流的前哨阵地，其转移状态评定对于淋巴结引流区域分期和治疗选择均有重要意义。通过腋窝前哨淋巴结活检，早期乳腺癌患者的腋窝淋巴结状态已经得到充分评定。对于术前全身新辅助治疗患者，淋巴结病理完全缓解被定义为腋窝淋巴结不存在癌转移，并且已被证实与生存结局改善存在相关性。不过，仅仅根据腋窝淋巴结状态，可能无法实现精准的淋巴结引流区域分期和淋巴结病理完全缓解诊断，可能导致分期偏低和治疗不足或过度。内乳前哨淋巴结活检为评定内乳淋巴结提供了比手术切除创伤较少的方法，并且可能影响淋巴结引流区域和全身治疗的决策。可是，由于临床意义不明确，常规开展内乳前哨淋巴结活检仍然存在争议。目前，现有指南未对内乳前哨淋巴结活检指征进行标准化。临床工作或研究仍然参考腋窝前哨淋巴结活检指征，仅对术前未接受全身新辅助治疗的临床腋窝淋巴结阴性患者进行内乳前哨淋巴结活检，结果发现内乳淋巴结转移比例仅8%～15%，并且对于治疗策略的影响微乎其微。既往乳房扩大根治切除术研究表明，腋窝淋巴结阳性患者的内乳淋巴结转移比例达28%～52%，而腋窝淋巴结阴性患者的内乳淋巴结转移比例仅5%～17%。因此，对于临床腋窝淋巴结阳性患者，可能通常需要调整淋巴结引流区域分期、淋巴结病理完全缓解诊断和治疗策略，可能真正受益于内乳前哨淋巴结活检。
2019年8月12日，美国乳腺外科医师学会和美国肿瘤外科学会《肿瘤外科学报》在线发表山东第一医科大学（山东省医学科学院）山东大学附属山东省肿瘤医院（山东省肿瘤防治研究院）王永胜等学者的研究报告，分析了临床腋窝淋巴结阳性乳腺癌患者内乳前哨淋巴结活检的内乳淋巴结转移比例，及其对淋巴结分期、淋巴结病理完全缓解诊断、全身或局部区域治疗策略的影响。
该单中心前瞻研究于2014年2月～2018年7月入组临床腋窝淋巴结阳性乳腺癌患者352例进行内乳前哨淋巴结活检。通过卡方检验、非参数秩次之和检验、逻辑回归模型进行统计学分析，差异显著标准为P<0.05。
结果，先手术后化疗、先化疗后手术患者分别为171例、181例，其中：
内乳前哨淋巴结可见患者：123例、60例（71.9%、33.1%，P<0.001）
内乳前哨淋巴结转移患者：49例、8例（39.8%、13.3%，P<0.00）
内乳前哨淋巴结活检成功患者共计183例、内乳前哨淋巴结可见共计347枚，每例患者耗时平均7分钟（4～28分钟）、可见内乳前哨淋巴结中位2枚（1～7枚）。内乳前哨淋巴结转移共计87枚，主要集中于第二、第三肋间隙（50.6%、34.5%）。183例内乳前哨淋巴结活检成功患者均获得更精准的淋巴结分期，其中57例分期提高，可能促使治疗策略进行调整。
因此，该单中心前瞻研究结果表明，临床腋窝淋巴结阳性患者应该常规进行内乳前哨淋巴结活检，从而获得更精准的淋巴结分期和更完美的病理完全缓解诊断。通过内乳前哨淋巴结活检确定内乳淋巴结转移，可能对治疗策略产生重大影响。
相关阅读
Ann Surg Oncol. 2019 Aug 12. [Epub ahead of print]
Internal Mammary Sentinel Lymph Node Biopsy in Clinically Axillary Lymph Node-Positive Breast Cancer: Diagnosis and Implications for Patient Management.
Peng-Fei Qiu, Rong-Rong Zhao, Wei Wang, Xiao Sun, Peng Chen, Yan-Bing Liu, Zhi-Guo Liu, Yong-Sheng Wang.
Shandong Cancer Hospital Affiliated to Shandong University, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China.
BACKGROUND: Routine performance of internal mammary sentinel lymph node biopsy (IM-SLNB) remains a subject of debate due to no clinical relevance in breast cancer, because it was performed only in clinically axillary lymph node (ALN)-negative patients. In this study, IM-SLNB was performed in clinically ALN-positive patients, and its impact on nodal staging and therapeutic strategy were subsequently analyzed.
METHODS: Clinically ALN-positive patients who underwent IM-SLNB were enrolled in this prospective study. Statistical analysis was performed using Chi square test, Mann-Whitney U and logistic regression models with a significance level of 0.05.
RESULTS: Among the 352 recruited patients, the internal mammary sentinel lymph node (IMSLN) visualization rate of patients who received initial surgery and neoadjuvant systemic therapy (NST) was 71.9% (123/171) and 33.1% (60/181), respectively. The 183 patients who underwent IM-SLNB successfully had the average time duration of 7 min and the median IMSLN number of 2. There were 87 positive IMSLNs in all the 347 removed IMSLNs, which were mainly concentrated in the second (50.6%) and third (34.5%) intercostal space. The IMSLN metastasis rate was 39.8% (initial surgery) and 13.3% (NST), respectively. All of the 183 IM-SLNB patients received more accurate nodal staging, 57 of whom had stage elevated, which might have prompted modifications to the therapeutic strategy.
CONCLUSIONS: IM-SLNB should be routinely performed in clinically ALN-positive patients, and thus more accurate nodal staging and perfect pathologic complete response definition could be put forward. The identification of IMLN metastases by IM-SLNB might potentially influence therapeutic strategies.
DOI: 10.1245/s10434-019-07705-0
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