目的:在对新辅助化疗(nact)反应良好的局部晚期乳腺癌(labc)女性患者中,包括内分泌治疗,与乳房切除术相比,保乳手术(bcs)的作用是什么?在labc的女性患者中,接受过乳房切除术的人是否需要放疗(rt)?局部rt,与单独的乳房或胸壁rt相比,导致更高的生存率和更低的复发率?对于那些对nact达到病理性完全缓解(pcr)的患者,前哨淋巴结活检(slnb)或腋窝清扫术是最合适的腋窝分期程序吗?是否在nact之前而不是在手术时表明slnb?如何治疗对初始nact无反应的labc女性患者?
方法:该指南由安大略省癌症护理计划的循证护理(pebc)和乳腺癌疾病研究小组(dsg)制定。根据1996年至2013年12月11日期间使用medline和embase数据库进行的文献检索,进行了系统评价。准则是从该搜索和主要准则组织的网站中找到的。工作组根据系统审查起草了建议。然后将系统审查和建议分发给乳腺癌dsg和pebc报告批准小组进行内部审查;修订后的文件经过外部审查。完整的三部分证据系列可以在安大略省癌症护理网站上找到。
结论:对于大多数labc患者,改良根治术应被视为护理标准.对于一些非炎性Labc患者,当外科医生认为疾病可以完全切除并且患者对保留乳房表现出强烈的偏好时,可以根据具体情况考虑bcs。对于患有Labc的患者,建议在乳房切除术后进行rt。建议,bcs或乳房切除术后,患有labc的患者接受局部rt,包括乳房或胸壁以及局部淋巴结区域。建议术后rt仍然是达到pcr至nact的labc患者的护理标准。建议腋窝清扫术仍是实验室腋窝分期的标准护理,在被告知当前数据局限性的患者中明智地使用slnb。尽管在nact之前或之后的slnb在技术上是可行的,数据不足以就nact的slnb的最佳时机提出任何建议。有限的数据表明,在nact之前进行slnb时,前哨淋巴结识别率较高,假阴性识别率较低;然而,如果在切除主要肿瘤时不进行slnb,则这些数据必须与两次手术的要求相平衡。建议接受基于蒽环类-紫杉烷的新辅助治疗(或其他序贯方案)的患者,其肿瘤对初始药物无反应,或者经历疾病进展的人,被加快到方案的下一个或多个药剂。对于那些,在主治医生看来,未能在一线nact上做出回应或进展,可以考虑几种治疗选择,包括二线化疗,激素治疗(如果合适),rt,或立即手术(如果技术上可行)。治疗应通过在多学科病例会议上的讨论进行个性化,考虑到肿瘤的特点,患者因素和偏好,和不利影响的风险。建议为对nact无反应的labc患者设计前瞻性随机临床试验,以便可以制定更明确的治疗建议。
OBJECTIVE: In female patients with locally advanced breast cancer (labc) and good response to neoadjuvant chemotherapy (nact), including endocrine therapy, what is the role of breast-conserving surgery (bcs) compared with mastectomy?In female patients with labc, is radiotherapy (rt) indicated for those who have undergone mastectomy?does locoregional rt, compared with breast or chest wall rt alone, result in a higher survival rate and lower recurrence rates?is rt indicated for those achieving a pathologic complete response (pcr) to nact?In female patients with labc who receive nact, is the most appropriate axillary staging procedure sentinel lymph node biopsy (slnb) or axillary dissection? Is slnb indicated before nact rather than at the time of surgery?How should female patients with labc that does not respond to initial nact be treated?
METHODS: This
guideline was developed by Cancer Care Ontario\'s Program in Evidence-Based Care (pebc) and the Breast Cancer Disease Site Group (dsg). A systematic review was prepared based on literature searches conducted using the medline and embase databases for the period 1996 to December 11, 2013.
Guidelines were located from that search and from the Web sites of major
guideline organizations. The working group drafted recommendations based on the systemic review. The systematic review and recommendations were then circulated to the Breast Cancer dsg and the pebc Report Approval Panel for internal review; the revised document underwent external review. The full three-part evidence series can be found on the Cancer Care Ontario Web site.
CONCLUSIONS: For most patients with labc, modified radical mastectomy should be considered the standard of care. For some patients with noninflammatory labc, bcs can be considered on a case-by-case basis when the surgeon deems that the disease can be fully resected and the patient expresses a strong preference for breast preservation.For patients with labc, rt after mastectomy is recommended.It is recommended that, after bcs or mastectomy, patients with labc receive locoregional rt encompassing the breast or chest wall and local node-bearing areas.It is recommended that postoperative rt remain the standard of care for patients with labc who achieve pcr to nact.It is recommended that axillary dissection remain the standard of care for axillary staging in labc, with the judicious use of slnb in patients who are advised of the limitations of the current data.Although slnb either before or after nact is technically feasible, the data are insufficient to make any recommendation about the optimal timing of slnb with respect to nact. Limited data suggest higher sentinel lymph node identification rates and lower false negative identification rates when slnb is conducted before nact; however, those data must be balanced against the requirement for two operations if slnb is not performed at the time of resection of the main tumour.It is recommended that patients receiving neoadjuvant anthracycline-taxane-based therapy (or other sequential regimens) whose tumours do not respond to the initial agent or agents, or who experience disease progression, be expedited to the next agent or agents of the regimen.For patients who, in the opinion of the treating physician, fail to respond or progress on first-line nact, several therapeutic options can be considered, including second-line chemotherapy, hormonal therapy (if appropriate), rt, or immediate surgery (if technically feasible). Treatment should be individualized through discussion at a multidisciplinary case conference, considering tumour characteristics, patient factors and preferences, and risk of adverse effects.It is recommended that prospective randomized clinical trials be designed for patients with labc who fail to respond to nact so that more definitive treatment recommendations can be developed.