[EBCC現場評論]王永勝教授：空芯針活檢診斷為導管內癌患者前哨淋巴結活檢研究

　　編者按：第10屆歐洲乳腺癌大會（EBCC）已經開始第二天的日程，《腫瘤瞭望》擷取會議重點摘要，邀請山東省腫瘤醫院乳腺病中心王永勝教授給予點評，以加深讀者對研究的理解。

研究一：導管內癌患者接受保乳手術可以避免前哨淋巴結活檢

　　活檢診斷為導管內癌（DCIS）的患者具有較高的浸潤性癌風險，接受乳房切除術時，指南推薦進行前哨淋巴結活檢（SLNB）。該研究旨在調研前哨淋巴結（SLN）轉移的發生率、有助於確定當前DCIS患者SLNB的指征與指南。

　　該研究入組荷蘭國家資料庫2004-2013年空芯針活檢診斷為DCIS、無臨床明顯可疑淋巴結的910例患者。51.8%的患者進行了SLNB，結果顯示94.5% pN0、3.0% pN1mi及2.5% pN1，接受乳房切除術及保乳手術的患者SLN的轉移率分別為7.0%和3.5%（P=0.107）。SLN轉移相關因素包括空芯針活檢組織量少（P=0.01）和升級為浸潤性癌（P<>

　　SLN總體轉移率為5.5%，其中接受保乳手術者3.5%、單純DCIS者2.0%。由此作者提出，空芯針活檢診斷為DCIS、接受保乳治療的患者不應再接受SLNB，術後病理證實升級為浸潤性癌的患者，可以二次手術進行SLNB。

研究二：荷蘭空芯針活檢診斷為DCIS患者SLNB的使用調研

　　荷蘭有關空芯針活檢診斷為DCIS患者腋窩分期與治療的國家指南並不明確，接受乳房切除術及DCIS診斷有低估風險（切除手術後升級為浸潤性癌）的患者考慮SLNB。通過分析不同醫院SLNB的使用差異並將其與低估率及SLN狀況比較，該研究的目的是評估空芯針活檢診斷為DCIS患者的處理質量。

　　通過荷蘭PALGA系統收集到2331例空芯針活檢診斷為DCIS的患者。88%的乳房切除術和51%的保乳手術患者接受了SLNB。不同醫院SLNB的使用存在顯著性差異。對於保乳手術患者，SLNB差異的44%源自醫院、10%源自醫院所屬的地區。診斷低估率和施行SLNB的相關因素包括DCIS分級和空芯針活檢病理存在可疑浸潤成分。保乳手術患者，切除術後病理仍為DCIS者和升級為浸潤性癌者SLNB比率分別為49%和62%，SLN微轉移和宏轉移的發生率分別為<>

　　空芯針活檢診斷為DCIS患者SLNB的使用在荷蘭不同醫院間並無一致的方針，反映了對國家指南不同的解讀。SLNB並未被高效使用。作者推薦在空芯針活檢診斷為DCIS的患者考慮使用SLNB。

專家點評

　　理論上常規病理診斷為單純DCIS者，無浸潤成分，不會出現腋淋巴結轉移，腋淋巴結分期屬於過度治療，但臨床工作中常規病理診斷為單純DCIS者出現腋淋巴結轉移的情況並不少見：國外報道SLN陽性率均值約為2.5%、國內CBCSG-001研究SLN的陽性率為3.4%。主要原因是病理取樣誤差導致了腫瘤中可能存在隱匿性的浸潤成分，多切面連續取材可以減少取樣誤差、DCIS可能升級為DCISM（DCIS微浸潤）或浸潤性癌，但病理取材的非連續性決定了取樣誤差的不可避免。微創活檢 (CNB/VAB) 病理取材存在局限，更易引起組織學低估，空芯針活檢診斷為DCIS患者接近20%術後升級為DCISM或浸潤性癌。國外報道空芯針活檢診斷為DCIS和DCISM患者SLN陽性率均值分別約為10.7%和13.0%。不同研究中共同的預測因素有：乳腺腫瘤較大、觸診可及、鉬靶攝片顯示腫物及高分級。

　　NCCN指南、ASCO SLNB指南更新及CACA乳腺癌SLNB臨床指南原則上推薦：明確為單純DCIS者，在未獲得浸潤性乳腺癌證據或者未證實存在腫瘤轉移時，不應進行ALND；仍有一小部分明顯為單純DCIS患者最後在進行手術時被發現為浸潤性癌；如果明顯為單純DCIS的患者準備接受全乳切除術或進行保乳手術，為避免手術部位（如腫瘤位於乳腺腋尾部）對將來SLNB可能帶來的影響，可考慮在手術當時進行SLNB。

　　為規範歐洲各國乳腺癌中心的規範化建設，歐洲乳腺癌宣言的達成進入到最後一年，相信基於荷蘭人群的大樣本回顧性隊列研究結果將有助於優化空芯針活檢診斷為導管內癌患者SLNB的規範、高效使用。

　　王永勝教授，研究員，二級教授，博士生導師，山東省腫瘤醫院乳腺病中心主任。山東省有突出貢獻的中青年專家，中國抗癌協會乳腺癌專業委員會常委，中華醫學會腫瘤學分會乳腺癌學組委員，中國醫師協會乳腺外科醫師委員會常委，國家衛計委乳腺癌診療規範專家組成員，NCCN乳腺癌指南中國版修訂專家組成員。

研究摘要

Sentinel lymph node biopsy can be omitted in DCIS patients treated with breast conserving therapy

Poster Spotlight: M. Vane (Netherlands)

Background: Breast cancer guidelines advise sentinel lymph node biopsy (SLNB) in patients with ductal carcinoma in situ (DCIS) on biopsy when at high risk of invasive breast cancer or in case of mastectomy. The aim of this study was to investigate the incidence of sentinel lymph node (SLN) metastases and relevance of indications in guidelines and literature to perform an SLNB in DCIS patients in current era.

Materials and Methods: Patients diagnosed from 2004–2013 with only DCIS on core biopsy without clinically suspicious lymph nodes were included from a national database. The incidence of SLN metastases was calculated. With Fisher exact tests correlation between indications in guidelines and literature for an SLNB and actual presence of SLN metastases was studied. The incidence of DCIS becoming invasive cancer was calculated and correlation with SLN metastases was studied.

Results: 910 patients were included. An SLNB was performed in 51.8%, which showed 94.5% pN0, 3.0% pN1mi and 2.5% pN1. Patients undergoing mastectomy had 7% SLN metastases versus 3.5% for BCT (p=0.107). The only factors correlated to SLN metastases were smaller core needle size (p=0.01) and upstaging to invasive cancer (p<0.001). invasive="" cancer="" was="" detected="" in="" 16.7%="" by="" histopathology="" with="" 15.6%="" sln="" metastases="" versus="" only="" 2%="" in="" solely="">

Conclusions: SLNB showed metastases in 5.5% of patients; 3.5% in case of BCT and 2% when solely DCIS at definitive histopathology. Consequently, an SLNB should no longer be performed in patients diagnosed with DCIS undergoing BCT. If definitive histopathology shows invasive cancer, it can be performed afterwards.

Use of the sentinel node biopsy for patients with a needle biopsy diagnosis DCIS in the Netherlands

Poster Spotlight: P. Westenend (Netherlands)

Background: Recommendations in the national guideline for diagnostic work up and treatment in patients with ductal carcinoma in situ (DCIS) at biopsy are ambiguous. A sentinel node (SN) biopsy is considered for patients undergoing mastectomy and for patients at risk for underestimate. Underestimate is defined as patients with a DCIS diagnosis at core needle biopsy for whom also an invasive breast cancer is found at excision. The aim of this study is to explore the quality of care for patients with a biopsy diagnosis DCIS. We analysed the hospital variation in use of the sentinel node biopsy and compared it with the underestimate rates and the SN results.

Materials and Methods: Patients with a final biopsy diagnosis DCIS were selected from the nationwide network and registry of histopathology and cytopathology in the Netherlands (PALGA). All PALGA records were assessed to extract DCIS grade, suspected invasive component at biopsy etc. The PALGA data were merged with the National Cancer Registry (NCR) data, thereby adding information about being screen-detected, palpable, BI-RAD score, hospital of treatment etc. In this study no information was available about the size of the mammographic lesion. Population based data from incidence years 2011 and 2012 were available for analysis. Multivariate analysis was conducted to define determinants of quality of care. Variation in care between hospitals were shown in plots and analysed in multilevel analysis.

Results: 2331 patients with a biopsy diagnosis DCIS were analysed. A SN biopsy was performed in 88% of patients undergoing mastectomy and in 51% of patients undergoing breast conserving surgery (BCS). The use of the SN biopsy differed significantly between hospitals. For BCS, 44% of the variance in % of SN biopsies was due to the hospital and 10% to the hospital region. Determinants for underestimation and determinants for performing the SN biopsy were DCIS grade and a suspected invasive component. Of patients undergoing BCS, the SN biopsy was performed in 49% of patients with a DCIS diagnosis at excision and in 62% of patients with an invasive cancer at excision. By SN biopsy at BCS, micro metastases were found in <1% and="" macro="" metastases="" in="" 2%="" of="" patients.="" of="" patients="" undergoing="" mastectomy,="" the="" sn="" biopsy="" was="" performed="" in="" 87%="" of="" patients="" with="" a="" dcis="" diagnosis="" at="" excision="" and="" in="" 90%="" of="" patients="" with="" an="" invasive="" cancer="" at="" excision.="" by="" sn="" biopsy="" at="" mastectomy,="" micro="" metastases="" were="" found="" in="" 3%="" and="" macro="" metastases="" in="" 4%="" of="">

Conclusions: We conclude that there is no uniform policy between hospitals in use of the sentinel node biopsy for patients with a biopsy diagnosis DCIS, reflecting differences in interpretation of the national guideline. The sentinel node biopsy is not used very effectively. We would recommend to reconsider the use of the sentinel node biopsy for patients with a DCIS at biopsy.

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(來源：《腫瘤瞭望》編輯部）