乳腺癌新辅助化疗后局部区域外科处理进展

目的探讨乳腺癌新辅助化疗后对局部区域的外科处理策略。方法对近年来有关乳腺癌新辅助化疗降期后保乳治疗、同侧乳房复发的相关因素、原发肿瘤病理退缩模式以及前哨淋巴结活检等局部区域的外科处理的相关文献进行综述。结果①新辅助化疗可使乳腺原发肿瘤降期，提高保乳手术的比率，但通过新辅助化疗降期后保乳手术患者可能存在较高的同侧乳腺肿瘤复发风险。目前比较趋于一致的影响新辅助化疗降期后保乳治疗的同侧乳腺肿瘤复发率的相关因素为残余肿瘤呈多中心模式、残余肿瘤直径〉2cm。新辅助化疗后原发肿瘤病理退缩模式及相关因素尚不明确。②新辅助化疗前、后前哨淋巴结活检（SLNB）均是可行的并获得指南与专家共识的认可，初始腋窝淋巴结阴性患者更能从新辅助化疗后SLNB中获益，初始腋窝淋巴结阳性患者新辅助化疗转阴性后行SLNB替代ALND的前景可期，但需要获得临床认可的成功率和假阴性率及与ALND相似的局部区域复发率及总生存率。结论无论乳腺癌新辅助化疗的临床和影像学疗效如何，外科处理仍然是目前降低局部区域复发风险的重要治疗手段。分子分型时代，我们可以依据乳腺癌初始分期及新辅助化疗的疗效对乳腺癌患者施行个体化的局部区域外科处理

Progress of Locoregional Surgery for Breast Cancer Patients after Neoadjuvant Chemotherapy

Objective To discuss the strategy of locoregional surgery for breast cancer patients after neoadjuvant chemotherapy. Method The pertinent literatures about locoregional surgery concerning breast-conserving therapy, factors of ipsilateral breast tumor recurrence, pathological shrinkage modes of breast primary tumor, and sentinel lymph node biopsy after neoadjuvant chemotherapy were reviewed. Results ①The major benefit ofneoadjuvant chemotherapy was to increase the proportion of breast-conserving therapy after downstaging the primary breast tumor. However, the use of breast-conserving therapy after neoadjuvant chemotherapy might remain a higher risk of ipsilateral breast tumor recurr- ence. It was now widely recognized that the risk factors for ipsilateral breast tumor recurrence were multifocal pattern of residual tumor and pathologic residual tumor larger than 2 cm. The shrinkage mode of the primary breast tumor after neoadjuvant chemotherapy and its relative factors were still unclear. ② Sentinel lymph node biopsy （SLNB） was feasible either before or after neoadjuvant chemotherapy and approval by SLNB guideline and expert consensus. Patients with a cN0 status could get more benefits from SLNB after neoadjuvant chemotherapy. Although there was a bright future for SLNB as an alternative to ALND for patients with primary cN1 and downstaging to cN0 after neoadjuvant chemotherapy, it needed to obtain the accepted clinical identification rate, false negative rate, as well as similar regional recurrence rate and overall survival as compared to ALND. Conclusions Currently, surgical management is crucial for reducing the locoregional recurrence risk of breast cancer after neoadjuvant chemotherapy, no matter what the clinical and radiographic efficacy ofneoadjuvant chemotherapy is. In the era ofgenomics and SLNB, individual locoregional surgical management could be arrived according to the primary stage and neoadjuvant chemotherapy response.