A Population-Based Study of the Effects of a Regional Guideline for Completion Axillary Lymph Node Dissection on Axillary Surgery in Patients with Breast Cancer
A Population-Based Study of the Effects of a Regional Guideline for Completion Axillary Lymph Node Dissection on Axillary Surgery in Patients with Breast Cancer
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DOI：
10.1245/s10434-016-5310-4
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发表时间：
2016-10-01
影响因子：
3.7
通讯作者：
Lovrics, Peter J.
中科院分区：
文献类型：
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作者：
Tsao, Miriam W.;Cornacchi, Sylvie D.;Lovrics, Peter J.
来自美国外科医师学会肿瘤组（ACOSOG）Z 0011试验的证据表明，在前哨淋巴结活检（+SLNB）阳性后完成腋窝淋巴结清扫（cALND）并不能改善特定患者的结局，导致实践差异。由外科医生、肿瘤学家和病理学家组成的多学科小组制定了cALND区域指南，并于2012年8月发布。我们评估了Z 0011和地区指南对cALND发生率的影响。我们回顾了12家医院接受SLNB的连续浸润性乳腺癌病例。收集了三个时间段的患者、肿瘤和过程指标：TP 1，Z 0011发表前（2009年5月至2010年8月）; TP 2，Z 0011发表后（2011年3月至2012年6月）; TP 3，指南发布后（2013年1月至2014年4月）。根据是否符合cALND的指南标准对病例进行分类（即，年龄> 50岁、乳房切除术、T3肿瘤、3个或更多个阳性前哨淋巴结[SLN]）或无（例如年龄> 50岁，保乳手术，T1/T2肿瘤，和一到两个阳性SLN）SLNB率从56%（n = 620）增加到70%（n = 774），TP 1、TP 2和TP 3中分别为78%（n = 844）。在使用指南标准不推荐cALND的病例中，cALND率随时间显著降低（TP 1，71%; TP 2，43%; TP 3，17%）[p < 0.001]。在使用指南标准推荐进行cALND的病例中，cALND率也随时间推移而降低（TP 1，92%; TP 2，69%; TP 3，58%）[p < 0.001]。多因素分析显示，年龄和淋巴结因素是决定cALND的重要因素，ACOSOG Z 0011的发表和地区指南的传播与+SLNB后cALND的显著下降相关，即使在指南推荐cALND的几个病例中也是如此。
Evidence from the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial suggests completion axillary lymph node dissection (cALND) after positive sentinel lymph node biopsy (+SLNB) does not improve outcomes in select patients, leading to practice variation. A multidisciplinary group of surgeons, oncologists, and pathologists developed a regional guideline for cALND which was disseminated in August 2012. We assessed the impact of Z0011 and the regional guideline on cALND rates.Consecutive invasive breast cancer cases undergoing SLNB were reviewed at 12 hospitals. Patient, tumor, and process measures were collected for three time periods: TP1, before publication of Z0011 (May 2009-August 2010); TP2, after publication of Z0011 (March 2011-June 2012); and TP3, after guideline dissemination (January 2013-April 2014). Cases were categorized by whether they met the guideline criteria for cALND (i.e. aecurrency sign50 years, mastectomy, T3 tumor, three or more positive sentinel lymph nodes [SLNs]) or not (e.g. age > 50 years, breast-conserving surgery, T1/T2 tumor, and one to two positive SLNs).The SLNB rate increased from 56 % (n = 620), to 70 % (n = 774), to 78 % (n = 844) in TP1, TP2, and TP3, respectively. Among cases not recommended for cALND using the guideline criteria, cALND rates decreased significantly over time (TP1, 71 %; TP2, 43 %; TP3, 17 %) [p < 0.001]. The cALND rate also decreased over time among cases recommended to have cALND using the guideline criteria (TP1, 92 %; TP2, 69 %; TP3, 58 %) [p < 0.001]. Based on multivariable analysis, age and nodal factors appeared to be significant factors for cALND decision making.Publication of ACOSOG Z0011 and regional guideline dissemination were associated with a marked decrease in cALND after +SLNB, even among several cases in which the guideline recommended cALND.