大肿瘤乳腺癌术前内分泌治疗腋窝降期

　　对于肿瘤较大的激素受体阳性乳腺癌，术前内分泌治疗可有效降低分期，并提高保乳手术的可行性和成功率。不过，关于术前内分泌治疗对腋窝完全病理缓解的数据极少。

　　2020年8月24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》在线发表纽约纪念医院斯隆凯特林癌症中心的研究报告，分析了术前内分泌治疗的腋窝和乳房降期率，并比较了术前内分泌治疗与术前化疗的腋窝缓解率。

　　该单中心回顾研究通过纽约纪念医院斯隆凯特林癌症中心前瞻维护数据库对2009年1月～2019年12月接受术前内分泌治疗和手术的连续125例患者127侧I～III期乳腺癌进行回顾分析。对2013年11月～2019年7月46例活检证实淋巴结阳性乳腺癌术前内分泌治疗患者与338例激素受体阳性HER2阴性乳腺癌术前化疗患者的淋巴结病理完全缓解比例进行比较。

　　结果，术前内分泌治疗与术前化疗的患者相比：

• 年龄较大

• 乳腺小叶肿瘤比例较高

• 肿瘤分级较低级

• 激素受体表达比例较高

　　术前活检证实淋巴结阳性乳腺癌患者术前内分泌治疗后：

• 淋巴结病理完全缓解比例为11%

• 乳房病理完全缓解比例为1.6%

　　术前内分泌治疗与术前化疗相比：

• 淋巴结降期比例相似：11%比18%（P=0.37）

• 淋巴结病理完全缓解患者年龄较大：中位70比50岁（P=0.004）

• 孕激素受体表达比例较高：85%比13%（P=0.031）

　　对于47例肿瘤较大故不适合保乳手术的患者，其中36例（77%）术前内分泌治疗后符合保乳手术条件，与仍不符合保乳手术条件的11例患者相比，孕激素受体表达比例显著较高（55%比5%，P<0.05）。

　　因此，该研究结果表明，虽然淋巴结病理完全缓解比例高于乳房病理完全缓解比例，但是术前内分泌治疗与腋窝手术相比，仍有助于乳房手术降级。不过，由于淋巴结病理完全缓解比例为11%，对于无明确术前化疗指征的患者，术前内分泌治疗仍然是淋巴结阳性乳腺癌患者降期的选择。

Ann Surg Oncol. 2020 Aug 24. Online ahead of print.

How Effective is Neoadjuvant Endocrine Therapy (NET) in Downstaging the Axilla and Achieving Breast-Conserving Surgery?

Giacomo Montagna, Varadan Sevilimedu, Monica Fornier, Komal Jhaveri, Monica Morrow, Melissa L. Pilewskie.

Memorial Sloan Kettering Cancer Center, New York, NY, USA.

BACKGROUND: Neoadjuvant endocrine therapy (NET) is effective in downstaging large hormone receptor-positive (HR+) breast cancers and increasing rates of breast-conserving surgery (BCS), but data regarding nodal pathologic complete response (pCR) are sparse. We reported nodal and breast downstaging rates with NET, and compared axillary response rates following NET and neoadjuvant chemotherapy (NAC).

METHODS: Consecutive stage I-III breast cancer patients treated with NET and surgery from January 2009 to December 2019 were identified from a prospectively maintained database. Nodal pCR rates were compared between biopsy-proven node-positive patients treated with NET, and HR+/HER2- patients treated with NAC from November 2013 to July 2019.

RESULTS: 127 cancers treated with NET and 338 with NAC were included. NET recipients were older, more likely to have lobular and lower-grade tumors, and higher HR expression. With NET, the nodal pCR rate was 11% (4/38) of biopsy-proven cases, and the breast pCR rate was 1.6% (2/126). Nodal-dowstaging rates with NET and NAC were not significantly different (11% vs 18%; P=0.37). Patients achieving nodal pCR with NET versus NAC were older (median age 70 vs 50, P=0.004) and had greater progesterone receptor (PR) expression (85% vs 13%, P=0.031), respectively. Of patients not candidates for BCS due to a large tumor relative to breast size, 36/47 (77%) became BCS-eligible with NET (median PR expression 55% vs 5% in those remaining ineligible, P<0.05).

CONCLUSION: Although nodal pCR is more frequent than breast pCR, NET is more likely to de-escalate breast surgery than axillary surgery. However, with a nodal pCR rate of 11%, NET remains an option for downstaging node-positive patients without clear indications for NAC.

DOI: 10.1245/s10434-020-08888-7