[Optimized regional lymph node management after neoadjuvant therapy in breast cancer].

内容摘要

Neoadjuvant therapy (NAT) has strengthened systemic control in breast cancer and promoted precision de-escalation of axillary management. For clinically node-negative patients, evidence supports sentinel lymph node biopsy (SLNB) after NAT; among human epidermal growth factor receptor 2(HER2)-positive and triple-negative breast cancer patients achieving breast pathological complete response, the risk of residual axillary metastasis is extremely low, suggesting the potential omission of axillary surgery. For clinically node-positive patients converting to node-negative (cN1➝ycN0) after NAT, targeted axillary dissection can reduce the false-negative rate of SLNB to 2%-4% with good local control, supporting SLNB as a substitute for axillary lymph node dissection. In patients with low-volume residual nodal disease, axillary radiotherapy is increasingly considered as an alternative to surgery, though long-term evidence is still required. With studies such as NSABP B-51 demonstrating reduced regional irradiation in selected patients, dual de-escalation of surgery and radiotherapy has become a research focus. Future advances in imaging, artificial intelligence, and circulating tumor DNA (ctDNA) may enable individualized axillary decision-making. 乳腺癌新辅助治疗（NAT）效果提升推动区域淋巴结处理向精准降阶转变。该文阐述了NAT后区域淋巴结优化策略：初诊腋窝阴性患者应在NAT后行前哨淋巴结活检（SLNB），其中人表皮生长因子受体2（HER2）阳性及三阴性且原发灶病理完全缓解者，腋窝转移风险极低，具备豁免手术潜力；初诊腋窝阳性且NAT后转为阴性（cN1降期为ycN0）者，采用靶向腋窝清扫可将SLNB假阴性率降至2%~4%，并取得良好控制，支持替代腋窝清扫；此外，前哨淋巴结低负荷残留患者中放疗替代手术趋势增强，但仍需长期随访；随着NSABP B-51研究显示特定患者可减少区域放疗，手术与放疗双降阶成为研究热点。未来结合影像、人工智能及循环肿瘤基因（ctDNA），可实现个体化腋窝淋巴结决策。.