+ o; I9 @* a: Y' [ Winchester醫師指出，此研究結果仍然會使得醫師不自主的使用完整 ALND。 " R* D0 J+ c$ s, [$ J; k 3 u6 G. L+ W/ c6 o 他在一篇聲明中表示，我們太過信賴手術，本報告指出，就存活率差異或局部復發差異來說，我們或許不需要動這個手術。這是一個與顯著發病率有關的手術。TVBNOW 含有熱門話題，最新最快電視，軟體，遊戲，電影，動漫及日常生活及興趣交流等資訊。( u' A6 ~: k0 S9 B8 Z
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他表示，舉例來說，完整ALND的水腫風險是30%至40%，SLNB則是2%至5%。 ' Y) p, b6 }" `# F' A6 j- i . G6 U9 Z4 w& [- d. Rwww.tvboxnow.com 研究作者表示，有時候需要完整ALND與否是個爭議，因而促使美國腫瘤外科醫師學會腫瘤小組(ACOSOG)進行 Z0011試驗比較這兩種方法。不過，在2004年，該試驗進行5年之後，因為新增病患太少而中止。 " i' |5 L& I8 Q8 M2 K! xTVBNOW 含有熱門話題，最新最快電視，軟體，遊戲，電影，動漫及日常生活及興趣交流等資訊。 * z3 a* K8 F$ c9 J8 P公仔箱論壇 Winchester醫師等人提出，ACOSOG Z0011的隨境分析顯示，69%的結節陽性病患拒絕納入試驗而繼續接受完整 ALND。他們也表示，即便有另一個比較這兩種方法的前溯臨床試驗，目前的研究結果可以為隨機指派到單用SNLB提供某些平衡點。 * [5 F+ A2 ]3 Q' M9 w+ D公仔箱論壇 ' E# {- }0 X) h. n8 ]2 X& ]www.tvboxnow.com 【實務上的改變】TVBNOW 含有熱門話題，最新最快電視，軟體，遊戲，電影，動漫及日常生活及興趣交流等資訊。' B1 o' R7 x+ `; V* w6 x2 m7 M
Winchester醫師等人使用國家癌症資料庫的臨床結節陰性乳癌女性，且接受SLNB以及在1998至2005年間有結轉移者的資料(n= 97,314)。 2 i8 u4 h" Z4 q" _# k 公仔箱論壇8 g! r) h" Y8 M8 C3 v
除了評估這些女性的結果，新研究的研究者也追蹤部份接受SLNB與完整ALND的病患。 2 Z }4 u: o6 j1 ]2 o7 x8 S8 R* B; e公仔箱論壇 TVBNOW 含有熱門話題，最新最快電視，軟體，遊戲，電影，動漫及日常生活及興趣交流等資訊。6 g8 [% ]8 O4 Y
結果指出，有關這些手術的實務有些改變。www.tvboxnow.com5 E& n9 \) a& }3 T
* K! L3 r. \! k7 |# H! q, l 主要研究作者、Karl Bilimoria醫師在聲明中表示，對於1998至2005年間的微小型結節疾病，單用SLNB而無完整結剝離者從大約25%增加到45%，至於有更明顯結轉移的病患(宏觀組)，其比例在整個研究期間相當穩定，當年在進行分析時，他是美國外科醫師學會研究員，現在是伊利諾州西北大學Feinberg醫學院外科住院醫師。9 i- C5 i6 p1 e& i
3 J2 `. L! [9 G 特別的是，單用SLNB治療宏觀型疾病的病患數量在這段期間內減少，從24.2%降到16.7%(P< .001)；不過，單用SLNB治療微小型疾病的病患增加，從24.7%增加到45.3% (P< .001)。 - c l% m8 [; l' j G9 dtvb now,tvbnow,bttvb + ~# b+ W6 A9 g- Q3 wwww.tvboxnow.com Bilimoria醫師推測，單用SLNB治療微小型疾病增加使得醫師有較多有趣的發現，並非每個病患都需要結節剝離。 0 W$ T9 ^( L$ F; _8 g, ^tvb now,tvbnow,bttvb 2 r3 V2 D v+ X pTVBNOW 含有熱門話題，最新最快電視，軟體，遊戲，電影，動漫及日常生活及興趣交流等資訊。 【後續詳細結果資料】tvb now,tvbnow,bttvb) ^0 n, {- f. B+ N& z
因為資料庫中追蹤5年的婦女人數有限，結果分析包括一小組婦女(n= 22,278)，且僅限於1998至2000年。該組平均追蹤63個月。 * @1 L- p0 O' wTVBNOW 含有熱門話題，最新最快電視，軟體，遊戲，電影，動漫及日常生活及興趣交流等資訊。 # y! R; D- G" Y# F 微小型結轉移病患中(n= 2203)，不論校正或未校正臨床-病理特徵、治療與醫院類型，單用SLNB(5個結節以下)與SLNB併用完整 ALND(9個結節以上)之間並無顯著差異。 $ C8 W) X- [$ [$ |0 hwww.tvboxnow.com - ~& [- u7 O2 a' v3 U5 g# P
宏觀型結轉移病患中(n= 20,075)，單一變項分析時，單用SLNB以及SLNB併用完整ALND之間的結果沒有顯著差異(腋下淋巴復發為1.0%vs1.2% [P = .40] ，相對存活為 98.5% vs98.2% [P= .72] ，觀察存活為82.1% vs81.8% [P= .55] )。 6 z* ?: K* J3 M) e; R 公仔箱論壇, b2 }" \; M) {1 P9 {, c4 i
不過，如前所述，校正臨床-病理特徵、治療與醫院類型之後進行分析時，對宏觀型疾病來說，相較於SLNB併用完整 ALND，單用SLNB治療傾向有不佳結果，但是沒有顯著差異。 + S- q9 o9 b; J P, Z* o 公仔箱論壇7 P& N( q6 F: R- |6 }; H% |
美國外科醫師學會住院醫師計畫臨床獎學金、西北大學Feinberg 醫學院外科支持本研究。 % i& L: Q. i3 I/ P& W' u# JTVBNOW 含有熱門話題，最新最快電視，軟體，遊戲，電影，動漫及日常生活及興趣交流等資訊。 ) ]' z' s' |/ S6 `7 `5 ? J Clin Oncol. 印刷前線上登載於2009年4月13日。 . U P& q0 `- f' S/ u! A6 I9 l % _; ?" ^- e( E m# x( B公仔箱論壇When Sentinel Lymph Node Biopsy is Enough in Breast Cancer / Z O* A# R( t5 Z: D q6 w: n公仔箱論壇www.tvboxnow.com, K8 c7 p# ^) j, N
By Nick Mulcahytvb now,tvbnow,bttvb. v- V0 [- g0 J" Z! {7 I
Medscape Medical News0 b3 R+ E, K/ D4 z9 o
TVBNOW 含有熱門話題，最新最快電視，軟體，遊戲，電影，動漫及日常生活及興趣交流等資訊。( W; E. ^+ H( y: E; u4 I
May 19, 2009 — It's a common dilemma for clinicians and their patients with breast cancer: whether or not to perform completion axillary dissection after nodal metastases have been identified by sentinel lymph node biopsy (SLNB).TVBNOW 含有熱門話題，最新最快電視，軟體，遊戲，電影，動漫及日常生活及興趣交流等資訊。" F% k5 |; y* h* Z* H6 k
% z7 D8 R# j- V. Atvb now,tvbnow,bttvbA new observational study of 22,278 women suggests that the answer is frequently no, especially if the nodal metastases are microscopic. The study was published online April 13 in the Journal of Clinical Oncology.+ ?7 i+ x' K( P/ C- W7 q
' O( S0 O6 c/ f& C* ctvb now,tvbnow,bttvbA full axillary dissection may not be necessary for most patients. 2 F8 p$ @+ z7 p% x : I8 N0 `8 j4 D, ^"A full axillary dissection may not be necessary for most patients," senior study author David J. Winchester, MD, told Medscape Oncology. Dr. Winchester is chief of the Division of General Surgery and Surgical Oncology at NorthShore University HealthSystem in Evanston, Illinois.TVBNOW 含有熱門話題，最新最快電視，軟體，遊戲，電影，動漫及日常生活及興趣交流等資訊。9 B) C/ p7 S3 O0 E- x# V1 b1 ^
3 r8 Q6 g2 f. R- V5 `! }7 i/ T公仔箱論壇He explained that, in the study, completion axillary lymph node dissection (ALND) did not improve outcomes in either axillary recurrence or survival for patients with microscopic disease. Furthermore, there may only be a small benefit with regard to those outcomes with completion ALND for those with macroscopic disease, he suggested.. B* I% b/ y9 q/ L3 k
* {8 h7 |) ?* ^: v6 g1 Wtvb now,tvbnow,bttvbIn patients with macroscopic nodal metastases, axillary recurrence and survival were comparable between the 2 treatment groups. + H6 r% ?/ p4 P+ M) M: w! E# @3 Y) k' itvb now,tvbnow,bttvb 1 I6 l' C2 Y' E+ s( L0 R8 [' sHowever, after the analysis was adjusted for differences between the 2 groups, there was a nonsignificant trend toward better outcomes for completion ALND than for SLNB alone — hazard ratio for axillary recurrence was 0.58 (95% confidence interval [CI], 0.32 - 1.06) and for overall survival was 0.89 (95% CI, 0.76 - 1.04), Dr. Winchester and colleagues report.TVBNOW 含有熱門話題，最新最快電視，軟體，遊戲，電影，動漫及日常生活及興趣交流等資訊。0 D( |# I. [! p0 c
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Still, the study results should cause clinicians to not automatically use completion ALND, noted Dr. Winchester. ' Y% P! X" z2 M% F' s ' U( @% b2 ]8 }8 G$ M2 m; BTVBNOW 含有熱門話題，最新最快電視，軟體，遊戲，電影，動漫及日常生活及興趣交流等資訊。We have relied upon that operation too much.tvb now,tvbnow,bttvb7 X6 O7 {* M/ d$ o/ ?+ m
. d J, y' t& I2 v"We have relied upon that operation too much, and this paper points out that we may not need to do it in terms of a survival difference or a regional recurrence difference. This is an operation associated with significant morbidity," he said in a statement. , Z, N* }9 O& ^9 t8 Q! ?3 y9 Pwww.tvboxnow.com公仔箱論壇& |5 V# k ]2 a# {, [9 f/ ~
For instance, the risk for edema is 30% to 40% with completion ALND, and 2% to 5% with SLNB, he said. ; ^ E8 l- D' J* ]) {0 P i; `公仔箱論壇 t2 {) g' N, yTVBNOW 含有熱門話題，最新最快電視，軟體，遊戲，電影，動漫及日常生活及興趣交流等資訊。The need for completion ALND has been debated for some time, and led to theAmerican College of Surgeons Oncology Group (ACOSOG) Z0011 trial comparing the 2 approaches, say the study authors. However, the trial was suspended after 5 years, in 2004, due to low patient accrual.公仔箱論壇# |3 v0 W1 `- v) \
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An ad hoc analysis of ACOSOG Z0011 showed that 69% of node-positive patients who refused to enroll went on to undergo completion ALND, Dr. Winchester and coauthors comment. They also say if there is ever another prospective clinical trial comparing the 2 approaches, then the current study's results could provide some "equipoise" for random assignment to SNLB alone.www.tvboxnow.com6 Q1 k7 `( r1 y/ s6 T9 r
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Shift in PracticeTVBNOW 含有熱門話題，最新最快電視，軟體，遊戲，電影，動漫及日常生活及興趣交流等資訊。8 [- K# o) t' e: M$ i2 P& ?
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Dr. Winchester and colleagues used data obtained from the National Cancer Data Base on women with clinically node-negative breast cancer who underwent SLNB and who had nodal metastases from 1998 to 2005 (n?= 97,314). 0 g' T/ i. x* d/ [9 {7 L uTVBNOW 含有熱門話題，最新最快電視，軟體，遊戲，電影，動漫及日常生活及興趣交流等資訊。TVBNOW 含有熱門話題，最新最快電視，軟體，遊戲，電影，動漫及日常生活及興趣交流等資訊。5 p0 U* p, Y& o7 H, f
In addition to evaluating outcomes in these women, the investigators of the new study tallied the proportion of patients undergoing SLNB and completion ALND. " j. ?; u& I0 i7 J + D" }' ]7 ~0 o6 T8 E3 jThe results indicate that there has been a shift in practice patterns concerning the procedures. + @- X5 [. r0 @公仔箱論壇 2 t& B3 k- ~' gwww.tvboxnow.com"For microscopic nodal disease from 1998 to 2005, the proportion of patients undergoing [SLNB] alone without a completion nodal dissection increased considerably, from about 25% to 45%, whereas for patients with more substantial nodal metastases (the macroscopic group), the proportion stayed fairly constant over the time course of the study," said study lead author Karl Bilimoria, MD, MS, in a statement. He was an American College of Surgeons Research Fellow at the time the analysis was performed, and is now a surgical resident at the Feinberg School of Medicine of Northwestern University in Evanston, Illinois.5 o/ C9 e! ]& J H5 ^
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Specifically, the proportion of patients who underwent SLNB alone for macroscopic disease declined during the study period, from 24.2% to 16.7%; (P?< .001); however, the proportion of patients who underwent SLNB alone for microscopic metastases increased, from 24.7% to 45.3% (P?< .001). $ s( K, H: D3 m. w! `' A公仔箱論壇TVBNOW 含有熱門話題，最新最快電視，軟體，遊戲，電影，動漫及日常生活及興趣交流等資訊。! i' _) _, B$ Z1 H6 i
Dr. Bilimoria speculated that the increase in the use of SNLB alone for microscopic disease arose as physicians "anecdotally found that nodal dissection is not necessary in all patients." % Y1 }! I; j0 O6 j2 {" N% Z' H" _/ _) O' N
Outcomes Data in Further Detailwww.tvboxnow.com* _( g& a# U0 n
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Because there was a limited number of women with 5-year follow-up in the database, the outcomes analysis comprised a smaller group of women (n?= 22,278) and was limited to the years 1998 to 2000. The group had a median follow-up of 63 months. ) y6 {3 K/ E+ N* `/ utvb now,tvbnow,bttvb $ \* {3 ^/ Y$ v$ e* d$ P1 gwww.tvboxnow.comIn patients with microscopic nodal metastases (n?= 2203), there was not a significant difference in outcomes between SLNB alone (5 or fewer nodes) and SLNB with completion ALND (9 or more nodes) — either unadjusted or adjusted for differences in clinico-pathologic characteristics, treatment, and hospital type. 8 j: j8 x$ v3 L6 _! \, \TVBNOW 含有熱門話題，最新最快電視，軟體，遊戲，電影，動漫及日常生活及興趣交流等資訊。4 _1 z6 r3 \6 R* U( q3 A
In patients with macroscopic nodal metastases (n?= 20,075), on univariate analysis, there was not a significant difference in outcomes between SLNB alone and SLNB with completion ALND (1.0% vs1.2% [P = .40] for axillary recurrence, 98.5% vs98.2% [P?= .72] for relative survival, and 82.1% vs81.8% [P?= .55] for observed survival). ( }' A @7 g) {: U2 B公仔箱論壇TVBNOW 含有熱門話題，最新最快電視，軟體，遊戲，電影，動漫及日常生活及興趣交流等資訊。 G, W0 |* s5 p8 e/ r+ X
However, as noted above, after the analysis was adjusted for differences in clinico-pathologic characteristics, treatment, and hospital type, there was a nonsignificant trend toward worse outcomes with SLNB alone than with SLNB with completion ALND for macroscopic disease. 9 x6 b) E3 o- H+ L* H; u Ywww.tvboxnow.com : T$ ~# Y: a0 z/ ^7 e9 j' c' _& }tvb now,tvbnow,bttvbThe study was supported by the American College of Surgeons Clinical Scholars in Residence program and the Department of Surgery, Feinberg School of Medicine, Northwestern University. , l2 L/ k. p9 {- p/ Btvb now,tvbnow,bttvb 6 K. e5 d: @5 ~J Clin Oncol. Published online before print April, 13 2009.
