早期乳腺癌腋窝手术降阶梯策略的研究进展与思考

Advances and reflections on de-escalation strategies for axillary surgery in early-stage breast cancer

摘要:

乳腺癌腋窝管理正经历由“最大耐受治疗”向“最小有效治疗”的降阶梯转变。前哨淋巴结活检（SLNB）的广泛应用显著减少了腋窝手术创伤，而近年来多项高质量前瞻性研究进一步推动了在特定早期乳腺癌人群中豁免腋窝手术的探索。SOUND和INSEMA试验证实，在严格影像学评估为cN0的T1~2期乳腺癌患者中，豁免SLNB在侵袭性无病生存方面不劣于SLNB，并可显著降低淋巴水肿等并发症的发生风险。导管原位癌、小体积低危肿瘤及≥70岁HR+/HER2-老年患者中，豁免腋窝手术对区域控制及生存率影响有限。随着影像学、正电子发射断层成像和人工智能技术的发展，基于多模态评估筛选cN0患者的准确率不断提高，部分新辅助治疗后达到乳腺病理完全缓解的HER2+/三阴性亚型患者亦显示出豁免腋窝手术的潜力。总体来看，精准患者选择是实施腋窝降阶梯策略的关键；但需关注分期信息缺失对后续系统治疗与放疗决策的影响。未来，在更成熟的循证证据和影像/病理评估技术支持下，腋窝手术将迈向更加个体化、精准化的管理模式。

Abstract:

Axillary management for early-stage breast cancer is shifting from maximal tolerated treatment to minimal effective intervention. The introduction of sentinel lymph node biopsy (SLNB) markedly reduced surgical morbidity, and growing evidence now supports omitting axillary surgery in selected patients. The SOUND and INSEMA trials demonstrated that, among strictly defined cN0 patients assessed by high-quality imaging, omission of SLNB is non-inferior to SLNB in terms of invasive disease-free survival while significantly reducing complications such as lymphedema. In ductal carcinoma in situ, low-burden tumors, and elderly patients aged ≥70 years with HR+/HER2- disease, omission of axillary staging has minimal impact on regional control and survival outcomes. Advances in imaging technologies, dedicated lymph node PET, and artificial intelligence have improved the accuracy of identifying true node-negative patients. Furthermore, highly selected HER2+/triple-negative patients who achieve breast pathologic complete response after neoadjuvant therapy may also be candidates for axillary surgery omission. Accurate patient selection remains central to safe de-escalation, although the loss of pathological staging information may influence subsequent systemic and radiation therapy decisions. With accumulating evidence and more refined assessment tools, axillary surgery is expected to evolve toward increasingly individualized and precise management.