乳腺癌摘要和讨论KwongPPT课件

.,1,NSABPPROTOCOLB-32,ARandomized,PhaseIIIClinicalTrialtoCompareSentinelNodeResectiontoAxillaryDissectioninClinicallyNode-NegativeBreastCancerPatients,DefinitiveAnalysisofthePrimaryOutcomes,DNKrag,SJAnderson,TBJulian,ABrown,SPHarlow,JPCostantino,TAshikaga,DWeaver,EPMamounas,NWolmark,ASCOAbstractLBA505,.,2,ADvs.noADRandomizedTrials,OrrRK.AnnSurgOncol1999;6(1):109-16,Survival,AlltrialsreportedhighersurvivalintheADgroup,.,3,Kragetal.AnnSurgOncol,2003.10(10):p.1-8.,1-5nodes,15nodes,Fewvs.Somevs.Many,Allnodesnegative,Survival,.,4,ClinicallyNegativeAxillaryNodes,GROUP1SN+AD,SNNeg(SNonly),GROUP2SN,StratificationAgeClinicalTumorSizeTypeofSurgery,B-32,SNpos+AD,SNPos,SNNeg(SN+AD),IntraopcytologyLouis-SylvestreC,JCO2004,22:97;VeronesiU,AnnOncol2005,16:383.,ALNDvs.AxRT,Author,MedianF/U,N,AxillaryRecurrence,AxRTvs.Obs,ALNDvs.Obs,Louis-Sylvestre,Veronesi,Martelli,5,219,0vs1.8%,5.3,435,0.5%vs1.5%,15,658,1%vs3%,Nosignificantdifferencesinsurvival,.,22,Hypothesis:SLNDaloneachievessimilarlocoregionalcontrolandsurvivalasLevelIandIIALNDforH8:793-802,2005,Diseasefreeandoverallsurvivalin4703patients,IHCdetectedLNoccultmets,IHCdetectedBMoccultmets,.,52,ACOSOGZ0010Schema,.,53,ACOSOGZ0010-Methods,BonemarrowaspirationpriortoSLNbxBonemarrowspecimenssubjectedtoIHC(investigatorsblindedtoresults)SLNsprocessed-standardpathologyandHasanoninvasive,accuratemethodofdeterminationofnodalstatusstillnotavailable,.,74,Importantfactsfromotherstudies,SLNfalsenegativerate5%innodepositivepatientsHoweverobservedrateofaxillaryrecurrenceafteranegativeSLNBisvanishinglysmall(0.3%in10clinicalseries,0.12%inotherstudies),Kim,Giulianoatal.Cancer2006;106:4-16;,.,75,SLNnegativepatients,Veronesietal(10yrresultsfromrandomisedcontrolledstudy)CompareoutcomesSLNnegativepatientswhoreceiveALNDvs.notNonsignificantdifferenceintermsofbreastcancer-relatedevents,localrecurrence/regionalordistantmetastasis),overallsurvival(althoughbothfavoredSLNarm)SLNBissafeasoncethestandardmethodofALNDforSLNnegativepatients,Veronesietal.2010AnnalsofSurgery.,.,76,Importantfactfromstudies,UnlikeSLNnegativepatients,abouthalfoftheSLNpositivemetastasisinremainingnon-SLNMSKCCnomogramsattemptstoselectthoseSLNpositivewhocanavoidALNDbuthavelimitationsTodatenoeasilydefinitiveidentifiablesubgroupofpatientswhoareSLNpositivecanavoidALNDtodate.,ParkJ,CodyHSetalAnnSurg2007;,.,77,EORTCAMOROSTrial,ComparesSLNpositivepatientswhoreceiveaxillaryradiotherapywithoutALNDvs.ALNDToplanfurthertherapy,ALNDisnotnecessary.SLNBislikelytobesufficientFalsenegativerateofSNBprocedureislowLowaxillaryrecurrenceSuggestedhypothesisthatALDNmaybeomitted(T1andT23cm)andtreatedwithradiationaloneNosurvivaldatayetparticularlymicrometastasisgroup,StraveretcalAnnSurgOncol2010,.,78,Micrometastasis,Morecontroversialtopic18%furthernodalinvolvementifSLNfoundtohavemicrometastasisLowbutnotnegligibleMeta-analysissuggestedpresenceofmicrometastasisinSLNisassociatedwithpoorerDFSandOSIsIHCoverdiagnosingLNmetastasis?,Boeretal.JNCI2010,.,79,NSABPB32,GoodsamplesizedprospectivestudytoaddressprognosticimplicationsofALNDandSLN.EmphasizedmorbiditycausedbyALNDvs.SLNBImportanceoflearningcurveandvalidationoftechniquesofsurgeonstominimizefalsenegativeresultsIMPORTANTStudyconfirmingthenecessityofavoidingALNDinsuitablepatientsparticularlyinSLNnegativegroupduetothenonsignificantdifferenceofoutcomebetweenthegroupswhichhadALNDvs.thegroupwhichonlyhadSLNB.,.,80,ACOSOGZ0011,AddressedsimilarissuetoAMOROSSTUDY,thatitisnotnecessarytohaveALNDinordertoplanadjuvanttherapyNodifferenceinprognosisandhencelikelythatSLNBaloneissufficientevenifLNareinvolvedforearlycancers,.,81,ACOSOGZ0011,ShouldallwomenwithpositiveSLNundergoaxillarydissection?WomenwhoundergoBCSwillhaveRTThisusuallyradiatesintotheloweraxillaryareaLiketohavelocoregionalcontrolandhencethegoodresultsfromthisstudy,.,82,ACOSOGZ0011,Ideaof“Targetedtreatment”Youngageandhighgradeisariskfactorofloco-regionalrelapseER-,olderagegroup,whetheradjuvanttherapyisgivenaffectssurvivalLongertermresultstoguideourpracticeFuture:decisionoffurtherALNDafterSLNBfoundpositivediseaseespeciallyifadjuvanttherapyisgoingtobegivenMSSKnomograms?Selectionbyriskfactorssuchasage,tumorbiologymayguidefuturedecisions,.,83,ACOZOGZ0010,MorecontroversialBalancebetweenover-diagnosingmicrometastasisandITCusingIHCoverH&ESomestudiessuggestsprognosticsignificanceformicromestastasis(egDutchgroup)LongerstudiesonsurvivalandprognosticimpactnecessarybeforeabandoningIHCStandardizationofpathologytechniquesimportantaspectsofsuchstudies,.,84,InConclusion,SLNnegativepatientsacceptabletoomitALNDa