1-王永胜-乳腺癌外科热点问题-0508-0510-1答案.ppt

* * * * * * * * * Individualizing Loco-Regional Therapy with NACAchievements and Promises Downsizing of the primary tumour Inoperable → Operable Mastectomy → Breast conserving surgery Breast conserving surgery → Better cosmesis In situ monitoring of the efficacy of systemic treatment to improve survival Promises Downstaging of the axillary lymph nodes Avoidance of ALND Reduction the extent of L-R XRT Potential for eliminating L-R therapy altogether Achievements 三大前瞻性研究数据汇总 ACOSOG Z1071 FN SNAC SENTINA 初始临床腋淋巴结状况cN cN1 only cN1-2 cN1 only 活检证实 腋淋巴结转移 YES YES NO Only 25% FNA+ NAC后腋淋巴结临床转阴性 NOT required NOT required YES – negative exam and US 腋淋巴结pCR 率 41.0% 34% 52% SLN是唯一阳性腋淋巴结 34.8% 三大前瞻性研究数据汇总 ACOSOG Z1071 FN SNAC SENTINA 汇总 入组患者数 649 141/153 592 1501 NAC后腋淋巴结阳性患者数 310 83 226 619 FNR 1个SLN 31.5% 17/54 18.2% 4/22 24.3% 17/70 26.0% 38/146 FNR ≥2 SLNs 12.6% 39/310 4.9% 3/61 9.6% 15/156 10.8% 57/527 FNR 双示踪剂 10.8% 27/251 _ 8.6% 6/70 10.3% 33/321 FNR ≥3 SLNs 9.1% 20/220 _ 4.9% 5/102 7.8% 25/322 新辅助化疗后腋窝处理 RECOMMENDATION 3.4: NACT SLNB may be offered before or after NACT, but the procedure seems less accurate after NACT 乳腺癌新辅助化疗后SLNB 2014 cN1 cN0 No further surgery ALND cN1 NAC SLNB cN0 NAC N0 N+ cN2,3 NAC 乳腺癌个体化治疗策略演变 优化全身治疗 Improving systemic therapy 优化患者选择 Improving patient selection 分类全身治疗 Tailoring patient drug selection 依据NAC疗效 个体化手术治疗 It is time to tailor surgical management based on disease response to NAC We do in the breast We CAN in the axilla 乳腺癌外科热点问题探讨 乳腺癌局部区域控制新理念 乳腺癌局部处理热点 乳腺癌保乳治疗疗效再探讨 SSO ASTRO 早期乳腺癌保乳治疗切缘指南 临床实践中如何获得保乳手术阴性切缘 乳腺癌的区域处理热点 ASCO 早期乳腺癌SLNB指南更新 腋窝低肿瘤负荷 ALND vs. RT 新辅助化疗后腋窝处理 内乳区处理 内乳淋巴结 分期与处理 内乳淋巴结清扫术 并发症多、手术时间长、更多的手术经验 早期研究结果未改善预后 影像技术 PET/CT, 超声, MRI 只能检出5mm的转移病灶 内乳区放疗(IMLN-RT) 内乳淋巴结高危转移患者 高危≠转移, 低危≠阴性 过度治疗 及 治疗不足 内乳区前哨淋巴结活检术(IM-SLNB) 内乳区微创分期技术 IM-SLNB指导下的个体化IMLN-RT Radiotherapy to Internal Mammary and Medial Supraclavicular (IM-MS) Lymph Nodes Improves Breast Cancer Survival European Cancer Conference 2013 (ECCO-ESMO-ESTRO).