Omission of breast surgery in exceptional responders after neoadjuvant chemotherapy-what are future possibilities?-a narrative review.

Frances Phang, Anna Weiss
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Abstract

Background and objective: Triple negative and human epidermal growth factor receptor 2 (HER2)-positive (+) tumors exhibit excellent response to systemic therapy and are known as "exceptional responders". Pathological complete response (pCR) rates have been reported in up to 64% of triple negative breast cancer (TNBC) and 66% of HER2+ patients. The idea of surgical omission has been studied for many decades, but how it will fit into breast cancer practice is unclear. The goal of this review is to provide a comprehensive discussion of the relevant literature surrounding omission of surgery and potential surgical de-escalation for multifocal/multicentric (MF/MC) tumors after neoadjuvant chemotherapy (NAC).

Methods: A literature search with relevant keywords was performed on the PubMed database and University of Rochester Edward Miner Library for studies ranging from 1989-2024. Types of studies included review articles, clinical trials and retrospective studies. A total of 49 studies were reviewed and summarized in this narrative review.

Key content and findings: It is difficult to accurately predict pCR after NAC. Physical exam and imaging are not accurate and image-guided biopsies can have false negative rates (FNR) up to 49.3%; however, with careful patient selection FNR can be as low as 2.9%. Surgical omission trials are ongoing with promising preliminary results, but sample sizes are small, and while physician attitudes towards surgical omission are generally positive, the proportion of patients willing to omit surgery is low. Instead of omission of surgery altogether, an alternative potential for surgical de-escalation is avoidance of mastectomy. The literature on surgical de-escalation for TNBC, HER2+ MF/MC tumors is scarce as most of the surgical omission studies were performed on unifocal tumors. If MF/MC tumors have similar biology and morphology, pCR of the primary site could serve as an indicator of response at the other satellite sites, but more research needs to be done in this area.

Conclusions: Surgical omission studies are ongoing with promising results. Patient attitudes and preferences of surgical omission should be considered as more clinical trials are planned. There is concern about the application of this concept broadly with the resources that are available. Large scale studies with longer follow-up is needed to confirm the safety of surgical de-escalation in this high-risk group of patients.

新辅助化疗后反应异常的患者省略乳房手术-未来的可能性是什么?-叙述回顾。
背景和目的:三阴性和人表皮生长因子受体2 (HER2)阳性(+)肿瘤对全身治疗表现出极好的反应,被称为“特殊反应者”。据报道,高达64%的三阴性乳腺癌(TNBC)和66%的HER2+患者的病理完全缓解(pCR)率。手术省略的概念已经被研究了几十年,但它将如何适用于乳腺癌的实践尚不清楚。本综述的目的是对新辅助化疗(NAC)后多灶/多中心(MF/MC)肿瘤的手术省略和潜在的手术降低风险的相关文献进行全面讨论。方法:在PubMed数据库和罗切斯特大学爱德华·迈纳图书馆检索1989-2024年的相关文献。研究类型包括综述文章、临床试验和回顾性研究。本文对49项研究进行了回顾和总结。关键内容和发现:NAC后pCR难以准确预测。体格检查和成像不准确,图像引导下的活检假阴性率(FNR)高达49.3%;然而,仔细选择患者,FNR可低至2.9%。手术遗漏试验正在进行中,初步结果令人鼓舞,但样本量很小,虽然医生对手术遗漏的态度总体上是积极的,但愿意省略手术的患者比例很低。而不是完全省略手术,另一个潜在的手术降级是避免乳房切除术。关于TNBC、HER2+ MF/MC肿瘤手术降压的文献很少,因为大多数手术遗漏研究都是针对单灶性肿瘤进行的。如果MF/MC肿瘤具有相似的生物学和形态,则原发位点的pCR可以作为其他卫星位点反应的指标,但在这方面还需要更多的研究。结论:手术遗漏研究正在进行中,结果令人鼓舞。在计划更多的临床试验时,应考虑患者对手术省略的态度和偏好。人们对利用现有资源广泛应用这一概念感到关切。需要更长的随访期的大规模研究来证实在这一高危患者群体中手术降压的安全性。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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