研究一：导管内癌患者接受保乳手术可以避免前哨淋巴结活检

　　活检诊断为导管内癌（DCIS）的患者具有较高的浸润性癌风险，接受乳房切除术时，指南推荐进行前哨淋巴结活检（SLNB）。该研究旨在调研前哨淋巴结（SLN）转移的发生率、有助于确定当前DCIS患者SLNB的指征与指南。

　　该研究入组荷兰国家数据库2004-2013年空芯针活检诊断为DCIS、无临床明显可疑淋巴结的910例患者。51.8%的患者进行了SLNB，结果显示94.5% pN0、3.0% pN1mi及2.5% pN1，接受乳房切除术及保乳手术的患者SLN的转移率分别为7.0%和3.5%（p?=?0.107）。SLN转移相关因素包括空芯针活检组织量少（p?=?0.01）和升级为浸润性癌（p?<?0.001）。16.7%的DCIS升级为浸润性癌，其SLN转移率为15.6%，而单纯DCIS患者SLN转移率仅为2.0%。

　　SLN总体转移率为5.5%，其中接受保乳手术者3.5%、单纯DCIS者2.0%。由此作者提出，空芯针活检诊断为DCIS、接受保乳治疗的患者不应再接受SLNB，术后病理证实升级为浸润性癌的患者，可以二次手术进行SLNB。

　　研究二：荷兰空芯针活检诊断为DCIS患者SLNB的使用调研

　　荷兰有关空芯针活检诊断为DCIS患者腋窝分期与治疗的国家指南并不明确，接受乳房切除术及DCIS诊断有低估风险（切除手术后升级为浸润性癌）的患者考虑SLNB。通过分析不同医院SLNB的使用差异并将其与低估率及SLN状况比较，该研究的目的是评估空芯针活检诊断为DCIS患者的处理质量。

　　通过荷兰PALGA系统收集到2331例空芯针活检诊断为DCIS的患者。88%的乳房切除术和51%的保乳手术患者接受了SLNB。不同医院SLNB的使用存在显著性差异。对于保乳手术患者，SLNB差异的44%源自医院、10%源自医院所属的地区。诊断低估率和施行SLNB的相关因素包括DCIS分级和空芯针活检病理存在可疑浸润成分。保乳手术患者，切除术后病理仍为DCIS者和升级为浸润性癌者SLNB比率分别为49%和62%，SLN微转移和宏转移的发生率分别为<1%和2%。乳房切除术患者，切除术后病理仍为DCIS者和升级为浸润性癌者SLNB比率分别为87%和90%，SLN微转移和宏转移的发生率分别为3%和4%。

　　空芯针活检诊断为DCIS患者SLNB的使用在荷兰不同医院间并无一致的方针，反映了对国家指南不同的解读。SLNB并未被高效使用。作者推荐在空芯针活检诊断为DCIS的患者考虑使用SLNB。

　　点评

　　理论上常规病理诊断为单纯DCIS者，无浸润成分，不会出现腋淋巴结转移，腋淋巴结分期属于过度治疗，但临床工作中常规病理诊断为单纯DCIS者出现腋淋巴结转移的情况并不少见：国外报道SLN阳性率均值约为2.5%、国内CBCSG-001研究SLN的阳性率为3.4%。主要原因是病理取样误差导致了肿瘤中可能存在隐匿性的浸润成分，多切面连续取材可以减少取样误差、DCIS可能升级为DCISM（DCIS微浸润）或浸润性癌，但病理取材的非连续性决定了取样误差的不可避免。微创活检 (CNB/VAB) 病理取材存在局限，更易引起组织学低估，空芯针活检诊断为DCIS患者接近20%术后升级为DCISM或浸润性癌。国外报道空芯针活检诊断为DCIS和DCISM患者SLN阳性率均值分别约为10.7%和13.0%。不同研究中共同的预测因素有：乳腺肿瘤较大、触诊可及、钼靶摄片显示肿物及高分级。

　　NCCN指南、ASCO SLNB指南更新及CACA乳腺癌SLNB临床指南原则上推荐：明确为单纯DCIS者，在未获得浸润性乳腺癌证据或者未证实存在肿瘤转移时，不应进行ALND；仍有一小部分明显为单纯DCIS患者最后在进行手术时被发现为浸润性癌；如果明显为单纯DCIS的患者准备接受全乳切除术或进行保乳手术，为避免手术部位（如肿瘤位于乳腺腋尾部）对将来SLNB可能带来的影响，可考虑在手术当时进行SLNB。

　　为规范欧洲各国乳腺癌中心的规范化建设，欧洲乳腺癌宣言的达成进入到最后一年，相信基于荷兰人群的大样本回顾性队列研究结果将有助于优化空芯针活检诊断为导管内癌患者SLNB的规范、高效使用。

　　专家简介

　　王永胜，研究员，二级教授，博士生导师，山东省肿瘤医院乳腺病中心主任。山东省有突出贡献的中青年专家，中国抗癌协会乳腺癌专业委员会常委，中华医学会肿瘤学分会乳腺癌学组委员，中国医师协会乳腺外科医师委员会常委，国家卫计委乳腺癌诊疗规范专家组成员，NCCN乳腺癌指南中国版修订专家组成员。

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 DCIS.

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?patients.

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.