Abstract：
The management of axillary lymph nodes in breast cancer is continually evolving. Recent data now support omitting axillary lymph node dissection (ALND) in most patients with metastases in up to two sentinel lymph nodes (SLNs) during upfront surgery and those with residual isolated tumor cells after neoadjuvant chemotherapy (NACT). In the upfront surgery setting, ALND is still indicated, however, in patients with clinically node-positive breast cancer or more than two positive SLNs and, after NACT, in case of residual micrometastases and macrometastases. Omission of the sentinel lymph node biopsy (SLNB) can be considered in many postmenopausal patients with small luminal breast cancer, particularly when axillary ultrasound is negative. Several randomized controlled trials (RCTs) are currently aiming at eliminating the remaining indications for ALND and also establishing omission of SLNB in a broader patient population. The movement to deescalate axillary staging is in part because of the association between ALND and lymphedema, which is swelling of an extremity because of lymphatic damage and obstructed lymphatic drainage. To reduce the risk of developing this condition, patients undergoing ALND can undergo reverse mapping of the axilla and immediate reconstruction or bypass of the lymphatics from the involved extremity. Decongestion and compression are the foundation of conservative treatment for established lymphedema, while lymphovenous bypass and lymph node transfer are surgical procedures to address the physiologic dysfunction. Radiotherapy is an essential component of breast locoregional therapy: more than three decades of radiation research has optimized treatment according to patient\'s risk of local recurrence while substantially reducing the number of treatment visits. High-quality RCTs have shown the efficacy and safety of hypofractionation-more than 2Gy radiation dose per treatment (fraction)-significantly reducing the burden of radiotherapy treatment for many patients with breast cancer. In 2024, guidelines recommend no more than 15-16 fractions for whole-breast and nodal radiotherapy, with some recommending five fractions for whole-breast radiotherapy. In addition, simultaneous integrated boost (SIB) has been shown to be noninferior to sequential boost with regards to ipsilateral breast tumor recurrence with similar or reduced long-term side effects, also reducing overall treatment length. Further RCTs are underway investigating other indications for five fractions, including SIB and regional node irradiation, such that, in future, it may be possible for the majority of breast radiotherapy patients to be treated with a 1-week course. This manuscript serves to outline the latest updates on axillary surgical staging, lymphatic surgery, and evidence-based radiotherapy in the treatment of breast cancer.
摘要：
乳腺癌腋窝淋巴结的管理正在不断发展。最近的数据现在支持在大多数患者中省略腋窝淋巴结清扫术（ALND），这些患者在前期手术期间在多达两个前哨淋巴结（SLN）中发生转移，而在新辅助化疗（NACT）后有残留的孤立肿瘤细胞。在前期的手术环境中，ALND仍然显示，然而,在临床淋巴结阳性乳腺癌或两个以上阳性SLN的患者中，在NACT之后，在残留的微转移和大转移的情况下。许多绝经后小管腔乳腺癌患者可以考虑省略前哨淋巴结活检（SLNB）。特别是当腋窝超声为阴性时。目前，一些随机对照试验（RCT）旨在消除ALND的其余适应症，并在更广泛的患者人群中省略SLNB。腋窝分期降低的运动部分是由于ALND和淋巴水肿之间的关联，这是由于淋巴损伤和淋巴引流阻塞引起的四肢肿胀。为了降低发展这种情况的风险，接受ALND的患者可以进行腋窝的反向定位,并从受累肢体立即重建或绕过淋巴管.缓解充血和压迫是对已建立的淋巴水肿进行保守治疗的基础，而淋巴静脉搭桥和淋巴结转移是解决生理功能障碍的外科手术。放射治疗是乳腺局部区域治疗的重要组成部分：超过三十年的放射研究已根据患者的局部复发风险优化治疗，同时大大减少了治疗次数。高质量的RCT已显示出大分割的有效性和安全性-每次治疗（分数）超过2Gy辐射剂量-显着降低了许多乳腺癌患者的放射治疗负担。2024年，指南建议全乳和淋巴结放疗不超过15-16次，有些人推荐五个部分用于全乳房放疗。此外,关于同侧乳腺肿瘤复发，同时整合增强（SIB）已被证明不劣于序贯增强，具有相似或减少的长期副作用，也减少了整体治疗的长度。进一步的随机对照试验正在调查五个部分的其他适应症，包括SIB和区域节点辐照，这样，在未来,大多数乳腺放疗患者可能接受为期1周的疗程治疗.这份手稿概述了腋窝手术分期的最新更新，淋巴手术,和循证放疗在乳腺癌治疗中的应用。
