The efficacy and oncological safety of minimally invasive axillary procedures in patients with node-positive breast cancer receiving neoadjuvant chemotherapy: A network meta-regression and trial sequential analysis

IF 3.5 2区医学 Q2 ONCOLOGY

Ejso Pub Date : 2025-02-20 DOI:10.1016/j.ejso.2025.109689

James Lucocq , Hassan Baig , Esther McNeill , J Michael Dixon

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引用次数: 0

Abstract

Background

Neoadjuvant chemotherapy (NAC) can downstage axillary nodes in breast cancer, prompting debate over the optimal axillary management after NAC. While axillary dissection (ALND) provides detailed assessment of node status, minimally invasive methods such as sentinel lymph node biopsy (SLNB), marked lymph node biopsy (MLNB) and targeted axillary dissection (TAD) are showing promise. This meta-analysis aims to assess the efficacy and safety of these strategies.

Methods

A systematic search of Medline, Embase and Cochrane Central was conducted and relevant RCTs were identified. Random-effects meta-analysis, meta-regression and trial sequential analysis (TSA) were conducted for diagnostic outcomes (identification rates [IFR], false negative rates [FNR] and negative predictive value [NPV]) and survival outcomes (overall survival [OS], disease-free survival [DFS]) to compare SLNB, MLNB and TAD with ALND.

Results

Twenty-eight studies (SLNB, n = 3392; MLNB, n = 1130; TAD, n = 946) investigated diagnostic outcomes and nine studies investigated survival outcomes (n = 5647). The pooled IFR, FNR and NPV of TAD was 96.8 %, 4.7 % and 93.2 %, respectively, and all values were superior to SLNB (91.9 %, 13.7 % and 84.8 %; meta-regression, p < 0.001) (SLNB vs. MLNB concordance = 73 %). The FNR of SLNB decreased with the number of nodes removed (≥3 nodes, 8.1 %) but remained inferior to TAD (p = 0.001). The IFR of SLNB in the ycN0 group was statistically lower than all patients (ycN0/+), 85.8 % vs. 91.9 % (p < 0.001). Pooled hazard ratios for DFS in SLNB/TAD, SLNB and TAD were 0.90 (95%CI, 0.77–1.04; p = 0.45), 0.89 (95%CI, 0.74–1.08; p = 0.25) and 0.91 (95%CI, 0.64–1.29; p = 0.58) (TSA 2.08>threshold). Indirect comparison between TAD and SLNB demonstrated no significant difference in DFS (HR 0.98; 0.64–1.32; 95%CI, p = 0.95).

Conclusion

Targeted axillary dissection is the optimal minimally invasive axillary technique in terms of diagnostic accuracy. De-escalation of axillary surgery following NAC does not negatively impact DFS in patients with node-positive breast cancer

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背景新辅助化疗（NAC）可降低乳腺癌患者腋窝结节的分期，从而引发了对新辅助化疗后最佳腋窝管理的争论。腋窝清扫术（ALND）可对结节状态进行详细评估，而前哨淋巴结活检术（SLNB）、标记淋巴结活检术（MLNB）和靶向腋窝清扫术（TAD）等微创方法正显示出良好的前景。本荟萃分析旨在评估这些策略的有效性和安全性。方法对 Medline、Embase 和 Cochrane Central 进行了系统检索，并确定了相关的 RCTs。随机效应荟萃分析、荟萃回归和试验序列分析（TSA）对诊断结果（识别率[IFR]、假阴性率[FNR]和阴性预测值[NPV]）和生存结果（总生存率[OS]、无病生存率[DFS]）进行了分析，以比较 SLNB、MLNB 和 TAD 与 ALND。结果28项研究（SLNB，n = 3392；MLNB，n = 1130；TAD，n = 946）调查了诊断结果，9项研究调查了生存结果（n = 5647）。TAD的集合IFR、FNR和NPV分别为96.8%、4.7%和93.2%，所有数值均优于SLNB（91.9%、13.7%和84.8%；元回归，p <0.001）（SLNB与MLNB的一致性=73%）。SLNB 的 FNR 随切除结节数的增加而降低（≥3 个结节，8.1%），但仍低于 TAD（p = 0.001）。从统计学角度看，ycN0 组 SLNB 的 IFR 低于所有患者（ycN0/+），为 85.8 % vs. 91.9 %（p < 0.001）。SLNB/TAD、SLNB 和 TAD 的 DFS 汇总危险比分别为 0.90（95%CI，0.77-1.04；p = 0.45）、0.89（95%CI，0.74-1.08；p = 0.25）和 0.91（95%CI，0.64-1.29；p = 0.58）（TSA 2.08>阈值）。TAD和SLNB的间接比较显示，DFS无显著差异（HR 0.98; 0.64-1.32; 95%CI, p = 0.95）。新农合后腋窝手术的降级不会对结节阳性乳腺癌患者的 DFS 产生负面影响

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来源期刊

Ejso 医学-外科

CiteScore

6.40

自引率

2.60%

发文量

1148

审稿时长

41 days

期刊介绍： JSO - European Journal of Surgical Oncology ("the Journal of Cancer Surgery") is the Official Journal of the European Society of Surgical Oncology and BASO ~ the Association for Cancer Surgery. The EJSO aims to advance surgical oncology research and practice through the publication of original research articles, review articles, editorials, debates and correspondence.