乳腺导管原位癌腋窝淋巴结转移风险评估与手术决策制定

Risk assessment of axillary lymph node metastasis and surgical decision-making in ductal carcinoma in situ

摘要

目的 探讨穿刺活检确诊的乳腺导管原位癌(DCIS)患者腋窝淋巴结转移的危险因素及分层管理策略,优化前哨淋巴结活检(SLNB)的临床决策。方法 回顾性分析2015年1月至2021年12月于西安交通大学第一附属医院经穿刺病理诊断为DCIS并行SLNB的352例乳腺癌患者的临床病理资料。通过单因素及多因素Logistic回归分析淋巴结转移相关危险因素。结果 51.1%(180/352)穿刺病理诊断为DCIS患者术后升级为浸润性癌(其中微浸润癌22.2%,pT1期及以上28.9%),总体腋窝淋巴结转移率为6.5%(23/352),且均发生于术后病理升级患者(纯DCIS无转移)。多因素分析显示,BI-RADS 4c分级(OR=4.29,95%CI:1.13~16.30)和穿刺病理怀疑浸润成分(OR=3.32,95%CI:1.30~8.45)为DCIS患者腋窝淋巴结转移的独立危险因素(均P<0.05)。在术后腋窝淋巴结转移组,主诉为可触及肿物(87.0% vs.53.5%,P=0.005)、综合影像学最大径≥20mm(60.9% vs. 41.0%,P=0.063)比例显著或临界性升高。结论 穿刺病理诊断为乳腺导管原位癌患者的术后病理升级为浸润性乳腺癌的风险较高,BI-RADS 4c分级及术前穿刺病理提示可疑浸润成分是淋巴结转移的核心预测指标。综合评估,可对乳腺癌患者的腋窝手术决策进行如下分层管理:拟行乳房切除术或存在高危特征(BI-RADS 4c/5级、中/高级别核分级、粉刺样坏死、可触及肿物或最大径>2cm)患者行常规前哨淋巴结活检;低危患者(BI-RADS≤4b级、低级别且无可疑浸润)可豁免前哨淋巴结活检。

Abstract

Objective To investigate independent risk factors for axillary lymph node metastasis (ALNM) and establish a stratified management strategy in patients who were diagnosed as breast ductal carcinoma in situ (DCIS) via core needle biopsy,so as to optimize clinical decision-making for sentinel lymph node biopsy (SLNB). Methods Clinical and pathological data of 352 patients with breast cancer (BC) who were diagnosed as DCIS via preoperative core needle biopsy and underwent SLNB in The First Affiliated Hospital of Xi'an Jiaotong University from January 2015 to December 2021 were retrospectively analyzed.Univariate and multivariate Logistic regression analyses were performed to identify risk factors that were associated with lymph node metastasis. Results Postoperative pathological upgrading to invasive carcinoma occurred in 51.1% (180/352) of BC patients who were diagnosed as DCIS via core needle biopsy before operation,including 22.2% of microinvasive carcinoma and 28.9% of pT1 or higher-stage tumors.The overall ALNM rate was 6.5% (23/352),and all metastatic cases occurred in patients with postoperative pathological upgrading (no metastasis observed in simple DCIS).Multivariate Logistic regression analysis showed that grade 4c in Breast Imaging-Reporting and Data System (BI-RADS 4c) ^{(OR=4.29,95%CI:1.13-16.30) and preoperative core needle biopsy pathological results suspecting invasive components (OR=3.32,95%CI:1.30-8.45) were independent risk factors (both P < 0.05).In the ALNM group,the proportions of patients who presented with palpable masses (87.0% vs.53.5%,P=0.005) and imaging-based maximum tumor diameter ≥20mm (60.9% vs.41.0%,P =0.063) were significantly higher compared with the non-ALNM group. Conclusion The patients with DCIS diagnosed via preoperative core needle biopsy face a potential risk of postoperative pathological upgrading to invasive breast cancer.BI-RADS 4c grade and preoperative core needle biopsy pathological results suspicion of invasive components are pivotal predictors of ALNM.After comprehensive evaluation,a stratified surgical strategy is recommended:routine SLNB should be performed for those patients who plan to undergo mastectomy or those with high-risk characteristics (such as BI-RADS 4c/5 grades,intermediate/high nuclear grade,comedonecrosis,palpable mass or tumor size >2cm).SLNB can be safely omitted in these low-risk patients with BI-RADS ≤4b grade or low nuclear grade without suspicious invasive components).}

关键词

乳腺 / 导管原位癌 / 前哨淋巴结活检 / 腋窝淋巴结转移 / 手术决策

Key words

breast / ductal carcinoma in situ / sentinel lymph node biopsy / axillary lymph node metastasis / surgical decision-making

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基金资助

国家自然科学基金青年科学基金项目(82504145)

西安交通大学第一附属医院国自然培育青年项目(No.2024-QN-30)

西安交通大学第一附属医院横向课题(HX202428)